<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623714
Report Date: 08/19/2021
Date Signed: 08/19/2021 09:43:31 AM

Document Has Been Signed on 08/19/2021 09:43 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MACK, TERESAFACILITY NUMBER:
313623714
ADMINISTRATOR:MACK, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 975-3148
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Teresa MackTIME COMPLETED:
10:00 AM
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
All times on this report are approximate. At 8:30a.m., on 8/19/21, Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, Teresa Mack, for the purpose of an unannounced required 1 year inspection. Prior to entry into the home, A COVID-19 risk assessment was conducted with licensee over the phone. The licensee's husband and assistant Kaela were also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. At 8:45 a.m., LPA observed a total census of 4 children including 1 infant age 12 months. At 8:50 a.m., Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include entire upstairs, laundry room and garage. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons nor poisons in the home. Toxic and hazardous items are inaccessible to children. There is no fireplace and stairs are barricaded to prevent access by children. Outdoor play space is fenced. LPA reminded licensee that any plastic wading pools must be drained when not in use.

At 9:00 a.m., LPA reviewed 4 children’s files and observed immunization records and emergency contact information. A current roster is being maintained and fire and disaster drills are documented and need to be updated at least once every six months. The licensee's and assistant's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires June 2022, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 11/2021. Licensee shall maintain Mandated reporter training certificates for all assistants.Report continues on 809-C.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MACK, TERESA
FACILITY NUMBER: 313623714
VISIT DATE: 08/19/2021
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
26
27
28
29
30
31
32
LPA observed one play yard at the facility. Play yard was free of loose objects. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

This provider is currently not providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/childqanda.htm.

LPA verified that the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.

This facility evaluation report was reviewed and discussed with Teresa Mack. A Notice of Site Visit was provided and shall remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.



In the areas that were evaluated, no deficiencies were observed at the time of the inspection.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2