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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408322
Report Date: 08/08/2023
Date Signed: 08/08/2023 05:01:15 PM

Document Has Been Signed on 08/08/2023 05:01 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:HAWKINS, SHAYVONFACILITY NUMBER:
073408322
ADMINISTRATOR:HAWKINS, SHAYVONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 467-5607
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Shayvon HawkinsTIME COMPLETED:
05:06 PM
NARRATIVE
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On August 8, 2023 at 2:03pm Licensing Program Analyst (LPA) Indira Loza met with Licensee Shayvon Hawkins for the purpose of conducting an unannounced 1-year annual inspection. Present during today's inspection were the Licensee, Licensee's Assistant, Unfingerprint cleared adult daughter, two minor children (not included in the ratio), one infant, and three preschool age children. The operating days and times are Monday - Friday 8am-5:00pm.

The home is a two story house with the upper level consisting of four bedrooms, and two bathrooms. The lower level of the house consists of a living room, dining room, kitchen, family room, half bathroom, a large backyard, and a garage.

On Limit Areas - the living room, kitchen, dining room, family room, and the backyard.
Off Limit Areas - Garage and the entire 2nd floor
ISOLATION AREA - in the living room

The home has a fully charged 2A10BC fire extinguisher, a working smoke detector in the hallway, a working carbon monoxide detector in the living room, and a working telephone. Licensee does not have Liability Insurance and had the "Affidavit Regarding Liability Insurance for Family Childcare Home" (LIC 282) in each child's file. The home has heating and ventilation for safety and comfort. LPA observed the backyard to be clean with plenty of toys and activities for the children in care. Licensee has ample age-appropriate toys and learning materials inside the home. Toxins, medicines, and hazardous items were inaccessible during today's inspection. Food is brought from home, with the children's containers labeled with the child's names. The Licensee had a current disaster drill, with the last drill taking place on August 4, 2023. LPA reviewed all four children's files and found the files to be complete. LPA provided the Licensee with the Infant Safe Sleep Regulations and a copy of the "Individualized Safe Sleep Plan" (LIC 9227).
**********************************Report Continues on LIC 809-C*******************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HAWKINS, SHAYVON
FACILITY NUMBER: 073408322
VISIT DATE: 08/08/2023
NARRATIVE
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 - Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02. When any IMS is 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 the ADA, available at: http://www.ada.gov/childqanda.htm

- Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
- 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 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.

During the Exit Interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



One type A and one type B deficiencies were issued during today's visit. See LIC809-D for the citations

The Licensee shall post a copy of this report and an Acknowledgement of Receipt of Licensing Reports (LIC 9224) to all parents of currently enrolled children, and children enrolled after 12 months of enrollment. The
*******************************Report Continues on LIC 809-C***********************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HAWKINS, SHAYVON
FACILITY NUMBER: 073408322
VISIT DATE: 08/08/2023
NARRATIVE
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Licensee shall also maintain the signed forms in the children's files for the next 12 months from today's date.

Exit interview conducted and report was reviewed with Licensee Sahyvon Hawkins.
Report and Appeal Rights were provided.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/08/2023 05:01 PM - It Cannot Be Edited


Created By: Indira Loza On 08/08/2023 at 04:00 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: HAWKINS, SHAYVON
FACILITY NUMBER: 073408322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as her adult daughter did not get fingerprinted once she turened 18 years old which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee shall ensure that the individual not return to the facility until they have obtained a Criminal Record Clearance. The LPA will be checking by returning to the facility within 10 days to verify compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/08/2023 05:01 PM - It Cannot Be Edited


Created By: Indira Loza On 08/08/2023 at 04:00 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: HAWKINS, SHAYVON
FACILITY NUMBER: 073408322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

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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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not have a current Mandated Reporter certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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The Licensee and her Assistant shall ensure to take the Mandated Reporter certificates and email them to the LPA no later than September 8, 2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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