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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409382
Report Date: 06/16/2023
Date Signed: 06/16/2023 10:11:46 AM

Document Has Been Signed on 06/16/2023 10:11 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:SMITH, ALISAFACILITY NUMBER:
073409382
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
06/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alisa SmithTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Cherie Acosta arrived at the home for an unannounced Case Management/Increase in capacity inspection. When LPA arrived licensee was not home. LPA was greeted by licensee's fingerprint cleared son, John Mixon. Also present in the home was fingerprint cleared adult, Vanessa Rodriguez-Williams. There were 5 children present during the inspection all of which are licensee's grandchildren. John Mixon is the father of 4 children present today. Licensee arrived at the home during the inspection.
Licensee has had a name change. Licensee provided documentation of the name change during the inspection. Licensee's name is now Alisa Grigsby.

Licensee has an approved fire clearance dated 5/12/23. Fire clearance is approved for 14 children. Fire clearance indicates that clearance is granted for the first floor only and is not approved for the garage.

The home was toured for a Health and Safety Inspection. The on limits area of the home include the living room/day-care area, formal dining room/day-care area, bathroom located near the day-care area, family room, kitchen and dining area. The remainder of the home is off limits to children in care. Off limits areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision The fenced backyard will be used for outdoor play. There are age appropriate toys in the home. There are no pools, hot tubs or any other similar bodies of water at this home. There are no firearms in the home as stated by the applicant. LPA did not observe any hazardous materials or toxins accessible to children today. The home is equipped with a working smoke detector and carbon monoxide detector. There is a working telephone in the home. The home has a fully charged 3A40BC fire extinguisher.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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: SMITH, ALISA
FACILITY NUMBER: 073409382
VISIT DATE: 06/16/2023
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Applicant 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.

The request to increase the capacity is approved effective today 6/16/23.
Exit interview and report was reviewed with Alisa Grigsby.
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
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