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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700341
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:18:40 PM

Document Has Been Signed on 04/13/2023 04:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:COLLVER, LISAFACILITY NUMBER:
015700341
ADMINISTRATOR:COLLVER, LISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 552-7187
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lisa CollverTIME COMPLETED:
04:25 PM
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On April 13, 2023 at approximately 11:45am Licensing Program Analyst (LPA) Haderer arrived unannounced for a 1-Year Required annual inspection. Present in the home today was licensee Lisa Collver, her fingerprint cleared helper Sahana Gudi, fingerprint and TB cleared husband Samuel Freeland and 14 children in care (2 infants; 5 two years old; 2 three years old; 3 four years old; 2 seven years old). The facility is in ratio today. The home was toured to conduct a health and safety inspection. The home is neat and clean with heating and ventilation for safety and comfort. Hours of operation for day care are Monday through Friday, 8:00am to 6:00pm.

The home is a single-story ranch stye house with 3 bedrooms, 2 1/2 bathrooms, kitchen, (plus a nook); a “great room” (former dining room with a fireplace now a play area), a living room (play area), a children’s ½ bath and attached 2-car garage. There is a large backyard play area divided up into 5 sections with farm animals and play structures. There are 3 pigs, 2 goats, (one goat has grown horns and as a result the pen is off limits to children). The perimeter of the property is surrounded by a fence. Licensee also has 2 cats, who LPA were told have current vaccinations. There are ample age appropriate toys.

Toxins, medicines, and hazardous items were inaccessible. Facility has a waiver for a woodburning stove.

ON LIMIT AREAS: Kitchen; dining room (great room); living room (play/activity room); 1/2 bathroom near front door, bedroom for napping infant off of the great room; backyard and front yards.

OFF LIMITS: The remainder of home: 2 back bedrooms, 2 bathrooms; attached 2-car garage; goat and pig pens in back yard area. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The outdoor play area and child playhouses were found to be free from defects or dangerous conditions.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 015700341
VISIT DATE: 04/13/2023
NARRATIVE
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There are ample age appropriate toys in good condition and activities available for children. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection.

The home has a fully charged 2A10BC fire extinguisher mounted on the wall of the great room; smoke detectors and carbon monoxide detectors were present; tested and working. There is a woodburning fireplace in the great room (day care area) with a waiver to not be used during childcare operations; always be cool to the touch, and a screen to prevent access to children. Liability insurance supplied by ACC and is current through 1/07/2024. If a child becomes ill during care, the isolation area will in the living room (play/activity room) away from the other children in care.

The licensee’s Health and Safety training is completed. Licensee’s CPR and First Aid certificate expired on 01/09/2023, since staff both have current certificates and are present during the day, a technical violation was issued. Mandated Reporter is expired for licensee and all staff – see LIC809D for deficiencies. Licensee and all staff are in compliance with immunization laws pertaining to family day care homes.

Licensee was reminded that CPR/1st Aide and Mandated Reporter training is to be renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. Per licensee, there are no firearms in the home.

Children files were reviewed, a roster was available and a photocopy taken by LPA for the office file. One newly enrolled 6-month old infant did not have any paperwork or a file for the following forms: Emergency Contact information; receipt of Parent’s Rights; Consent for Emergency Medical Treatment; Infant Safe Sleep Plan; and immunization records - see LIC809D for deficiencies. Sleep logs for infants were maintained but not kept for archive. A technical violation was issued and a reminder issued.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 015700341
VISIT DATE: 04/13/2023
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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, available at: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

There were 6 deficiencies issue today, see LIC809D for details:


Mandated Reporter certificates for all staff are expired and need to be renewed (AB1207)
Child files for recently enrolled infant child including the following forms:
- Emergency ID and contact form
- Signed receipt of Parent’s Rights form
- Consent for Emergency Medical Treatment form
- Immunization records
- Infant Safe Sleep Plan (and associated sleep logs)

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Lisa Collver.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/13/2023 04:18 PM - It Cannot Be Edited


Created By: Russell Haderer On 04/13/2023 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 015700341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that licensee and staff's Mandated Reporter (child care provider AB1207) have all expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2023
Plan of Correction
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Licensee and staff to renew their Mandated Reporter certificates (Child Care Provider AB1207) and going forward renew them every two years.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that immunization records not available for recently enrolled infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee to collect all required immunization records for infant and maintain them on the immunization record document.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/13/2023 04:18 PM - It Cannot Be Edited


Created By: Russell Haderer On 04/13/2023 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 015700341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that signed Parent's Rights form not available for recently enrolled infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee to issue LIC995A Parent's Rights documentation to parent and collect the signed/dated proof of receipt and maintain this in the child's file.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Emergency ID card not available for recently enrolled infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee to collect completed Emergency ID form for child in care and maintain this in the child's file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/13/2023 04:18 PM - It Cannot Be Edited


Created By: Russell Haderer On 04/13/2023 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 015700341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that Parents signed emergency consent for medical treatment form not available for recently enrolled infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee to collect completed Consent for Emergency Medical Treatment form for child in care and maintain this in the child's file.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Infant Safe Sleep Plan not available for newly enrolled 6 month old infant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee to collect completed LIC9227 Infant Safe Sleep Plan for child in care and maintain this in the child's file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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