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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070203461
Report Date: 10/20/2021
Date Signed: 10/20/2021 04:59:50 PM

Document Has Been Signed on 10/20/2021 04:59 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SMITH, HENRIETTAFACILITY NUMBER:
070203461
ADMINISTRATOR:SMITH, HENRIETTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 235-3631
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Henrietta SmithTIME COMPLETED:
05:13 PM
NARRATIVE
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On October 20, 2021, Licensing Program Analyst (LPA), Caroline Colson met with Henrietta Smith and her assistant, Jorge Montano III for an unannounced random annual inspection at 2:17 PM. The home was toured to conduct a Health and Safety Inspection. The facility's operating hours are 6:00 AM to 6:00 PM on Mondays - Fridays and on weekend as needed.

The home is a one story home. The home consist of two bedrooms, living room, kitchen, one bathroom, fenced front yard, fenced back yard and a garage. The fenced front yard will be used for the outdoor play space. The master bedroom and garage will be the inaccessible areas. There is 2A10BC fire extinguisher, a working smoke and a working carbon monoxide detector. She has central heating. Ms. Smith states that there are no firearms in the home. There are toys available for the children. Her CPR and First Aid certificates are current and expire on June 21, 2023. The isolation area will be the first bedroom on the left hand side. There is one dog.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.

Please See LIC 809 C for additional information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SMITH, HENRIETTA
FACILITY NUMBER: 070203461
VISIT DATE: 10/20/2021
NARRATIVE
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· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov


· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a 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 ADA, available at: http://www.ada.gov/childquanda.htm

The attached type A deficiency are being cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

Please See LIC 809 C for Additional Information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/20/2021 04:59 PM - It Cannot Be Edited


Created By: Caroline Colson On 10/20/2021 at 04:07 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SMITH, HENRIETTA
FACILITY NUMBER: 070203461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in one adult working at the facility without a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2021
Plan of Correction
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2
3
4
Licensee will ensure all staff have a criminal record clearance before working at the family day care home.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Caroline Colson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/20/2021 04:59 PM - It Cannot Be Edited


Created By: Caroline Colson On 10/20/2021 at 04:20 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SMITH, HENRIETTA
FACILITY NUMBER: 070203461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)


This requirement is not met as evidenced by: 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.
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in C1, C4, C5 and C7 not having immunization records available for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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2
3
4
Licensee will ask the parents to bring the immunization records and complete the immunization card for each file.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Caroline Colson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SMITH, HENRIETTA
FACILITY NUMBER: 070203461
VISIT DATE: 10/20/2021
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The attached type B deficiency is being cited today and must be corrected by the due date. Notice of site visit was posted at the time of the inspection and must be posted for 30 days. An exit interview was conducted.

Appeal rights were given and discussed. This report must be available for public review for 3 years.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5