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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409226
Report Date: 04/14/2023
Date Signed: 04/14/2023 10:59:09 AM

Document Has Been Signed on 04/14/2023 10:59 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, 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:
04/14/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shawn PowersTIME COMPLETED:
11:00 AM
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On 04/14/2023 at 9:30AM, Licensing Program Analyst (LPA), Diana Campos met with licensee Shawn Powers to conduct an in-person Case Management inspection for a Capacity Increase. No children were present during today's inspection . The entire home was toured to conduct a health and safety inspection with licensee. Hours of operation for day care are Monday through Friday, 6:30AM to 6:00PM.

Community Care Licensing (CCL) has received an approved fire clearance.

This is a one story home which consists of 5 bedrooms, 2 bathrooms, Living room, dining room, family room, kitchen, laundry room, garage and enclosed back yard. There is central heating and ventilation for the safety and comfort of children in care. The fireplace is screened to prevent access by children in care. Areas used for day care will be the formal living room, the dining room, the family room, the kitchen, the hall bathroom and the fully fenced back yard. The off limit areas are all five bedrooms which includes the master bedroom and master bathroom, the laundry room, and the garage. Off limit areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. The fenced backyard will be used as the outdoor play area. There are age appropriate toys in the home. There are no firearms in the home as stated by the licensee. There is one pet bird. LPA did not observe any hazardous materials or toxins accessible to children today.
The home has a fully charged 2A10BC fire extinguisher. The home is equipped with working smoke detectors and carbon monoxide detector. There is a working telephone in the home. The applicant’s CPR and First Aid certificate is current and expires 10/2023. Licensee completed mandated reporter training which expires 10/2023. Licensee is in compliance with immunization requirements. LPA did not observe any bodies of water.
See 809-C for continuance.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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: POWERS, SHAWN
FACILITY NUMBER: 073409226
VISIT DATE: 04/14/2023
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Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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.


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. 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

No deficiencies cited during today's inspection.

The home is recommended for a Capacity Increase as of today.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Shawn Powers.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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