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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700009
Report Date: 08/27/2021
Date Signed: 08/27/2021 11:29:35 AM

Document Has Been Signed on 08/27/2021 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:WILLIAMS, ASHLEYFACILITY NUMBER:
015700009
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ashley WilliamsTIME COMPLETED:
11:45 AM
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On 8/27/2021 Licensing Program Analyst (LPA) Jaylena Miller, met with licensee Ashley Williams for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for the inspection were licensees fingerprint cleared/associated mother and 3 day care children. The home was toured to conduct a Health and Safety Inspection. The licensee is within ratio today.

The home is a single-story home with 3 bedrooms, 2 bathrooms, living room, den, kitchen, dining room, garage with laundry room and back yard. The home appears to be neat and clean with central heating and ventilation for safety and comfort. The home does have a fireplace that is screened to prevent access to children.

The OFF-LIMIT AREAS are the first bedroom (converted into office), second bedroom, the master bathroom and the garage and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the master bedroom only, living room, kitchen, dining room, and den which is the main daycare area. The children will use the bathroom adjacent to the master bedroom. The designated isolation area will be the family room. The backyard will be a designated outdoor play area that is fully fenced. The outdoor area has age appropriate toys that appear to be clean and free from defects and dangerous conditions.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 2A-10-BC, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubes or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises.

The licensee completed the Health and Safety training, CPR/First Aid is current and expires on 4/23/2023. The licensee is in complaint with the immunization laws and has completed the mandated reporter training on 8/11/2021. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 7/30/2021. Facility roster reviewed and copy obtained. All required forms are posted and visible for public review.

Please see LIC 809-C for continuance

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WILLIAMS, ASHLEY
FACILITY NUMBER: 015700009
VISIT DATE: 08/27/2021
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LPA Miller provided a copy of Safe Sleep Regulation Concept (infants) to the licensee. The licensee was reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care. LPA also discussed the individual infant sleep plan (LIC 9227) and sleep logs for infants.

LPA also discussed with Licensee that ALL assistants, volunteers, frequent visitors, or adults living in the home, over the age of 18, must be fingerprint cleared and associated to the home prior to being in the presence of children in care. An immediate civil penalty will be assessed from $100 to $3000 per person, per incident.

Licensee was reminded of the responsibility as a mandated reporter and the mandated reporter training is required to be renewed every two years by visiting www.mandatedreporterca.com. CPR/First Aid must also be renewed every two years and be EMSA approved. LPA also encouraged Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, as well as all forms can be downloaded.

Individual Medical Services (IMS) policy was discussed. The Licensee is reminded that when any changes to the IMS plan is made, an updated Plan for Providing IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA information line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care centers and the ADA website at: http://www.ada.gov/childqanda.htm.



For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

Effective August 1, 2003 California Law requires Family Childcare Home licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury for (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail and the written report (LIC 624) must be submitted within 7 business days.

LPA Miller did not review children’s files or facility file due to COVID-19.

An exit interview was conducted with the licensee. No deficiencies were cited during today’s inspection. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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