115407902-6-29-2021-13-CC-LCHZ-C4FUKQ-20210629153932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 115407902
Report Date: 05/19/2021
Date Signed: 06/29/2021 03:39:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	BERLIN, SHIRLYN FAMILY CHILD CARE HOME		FACILITY NUMBER:	115407902
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 1	DATE:	05/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Shirlyn Berlin		TIME COMPLETED:	12:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/19/2021 at 11:00am, Licensing Program Analyst (LPA) Laura Chavez conducted a prelicensing inspection in response to an application for a capacity of 8. The inspection was conducted via tele-inspection due to the current State of Emergency caused by COVID-19. During today's tele-inspection LPA and licensee discussed information regarding COVID-19. The Property Owner Landlord Notification and Property Owner/Landlord Consent are on file. Days and hours of operation will be Monday-Friday; 7:00am-5:00pm. The applicant understands that child care must be provided in the "primary" residence of the applicant. The applicant understands that 24 hour care shall not be provided to one child at any one time. The home was toured inside and out. The floor and yard plan were verified. The residence is a three bedroom/two bath home. The three bedrooms, master bathroom, laundry room, covered storage area and garage are off-limits. These areas have been made off-limits by means of locks and doorknob covers. A gate surrounds the fireplace making it inaccessible to children in care. Two adults and two minors reside in the home. The home is clean and orderly at this time and will remain so during child care hours. Electrical outlets were covered and cords to window blinds were not accessible. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. Poisons are locked in the garage. There are age appropriate toys available for the children. There is a working smoke detector, carbon monoxide detector and a fully charged fire extinguisher in the home. The firearms and ammunition are locked as required. Notification of Parents Rights, Emergency Disaster Plan with the Earthquake Preparedness Checklist shall be posted. The doors leading into the garage and laundry room from the enclosed patio are locked. Report continued: See LIC 809-C

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura Chavez	TELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: BERLIN, SHIRLYN FAMILY CHILD CARE HOME	FACILITY NUMBER: 115407902
	VISIT DATE: 05/19/2021

NARRATIVE

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The children will use the back yard as the outdoor play area and it is fully fenced. The climbing/swing/slide structure in the backyard is in good repair. The applicant agrees that the play structure shall be used per manufactures instructions. There is no pool, spa, or ponds, nor any other source of water accessible to the children, and none of these items are to be added without prior notification and approval of the licensing agency. The applicant understands that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. The applicant understands that parents will be required to sign insurance affidavits should the applicant not does not carry liability insurance for her family child care home. A sample of forms typically given during prelicensing visits were provided and reviewed. The applicant understands that the child care roster shall remain current at all times. Children's records are to be maintained and kept current at all times. The applicant was reminded of the responsibility of reporting unusual incidents to CCLD within 24 hours or the next business day. Megan's Law is available at www.meganslaw.ca.gov/. The following information regarding the American Disabilities Act (ADA) was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at https://www.ada.gov/childqanda.htm. The applicant clearly understands the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be one child in kindergarten or elementary school and one child at least age 6. Smoking is prohibited during the hours of operation. The applicants understand the responsibility of securing copies of forms and regulations from the website (www.ccld.ca.gov).

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

The home is in compliance and thereby granted licensure.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura Chavez	TELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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