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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409226
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:04:32 PM

Document Has Been Signed on 12/16/2021 04:04 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:POWERS, SHAWNFACILITY NUMBER:
073409226
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/16/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:SHAWN POWERSTIME COMPLETED:
04:00 PM
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10:30AM Licensing Program Analyst Tasha Alexander met today with Shawn Powers for an ANNOUNCED PRE-LICENSING INSPECTION. Applicant, her adult daughter and minor grandson are present for the inspection. The home is a one story house consisting of 5 bedrooms, 2 bathrooms, living room, family room, kitchen and garage. The living room, family room, hall bathroom, kitchen and backyard will be the primary areas for day care. The off limits areas will be the laundry room/area, all 5 bedrooms and garage. These areas will be inaccessible to children in care by closed and/or locked doors and visual supervision. Applicant and her husband own the home; proof was shown. Per applicant there are no firearms/weapons located on the premises. There is a 20A10BC fire extinguisher in the home. The smoke alarm and carbon monoxide detectors were both tested today and is in working condition; recommended periodic servicing. There are no swimming pools, hot tubs or other bodies of water located on the premises. All sharp knives, cleaning solutions and medications are inaccessible to be made inaccessible to children by latching the kitchen cabinet. First aid kit is available and complete. The isolation area for sick children will be an area in the family room. Outdoor play will be in the backyard park. There are toys and play space available. Applicant was instructed to conduct and document periodic fire and disaster drills. Applicant was informed that baby walkers, exersaucers and baby bouncers are not allowed. Applicant has completed CPR and first aid training which expires in 10/8/2023 respectively. Applicant has completed her 16 hours of health and safety training which included the 1 hour of Nutrition and 1 hour of Lead poisoning training.

Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies given to applicant. Applicant was instructed on the law establishing a $100 fine per day for adults who are living in the home or who are providing care who do not have fingerprint clearances. Applicant was also instructed on the law requiring notification to parents regarding exclusions.
All forms can be downloaded at www.ccld.ca.gov. www.myccl.gov for day-care updates.
CONTINUED ON 809-C`
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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: POWERS, SHAWN
FACILITY NUMBER: 073409226
VISIT DATE: 12/16/2021
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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 the ADA, available at: http://www.ada.gov/childqanda.htm

DURING TODAY'S PRE-LICENSING INSPECTION THE RESOURCE MATERIALS FOR COVID-19 WERE ALSO DISCUSSED TO HELP THE FACILITY STAY SAFE DURING THIS PANDEMIC.

As a result of today's visit, no deficiencies are cited. This home will be licensed as of today 12/16/21. Congratulations!



An exit interview was conducted.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC809 (FAS) - (06/04)
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