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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623714
Report Date: 08/09/2023
Date Signed: 08/09/2023 01:09:04 PM

Document Has Been Signed on 08/09/2023 01:09 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 14CENSUS: 13DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Teresa MackTIME COMPLETED:
01:20 PM
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On August 9, 2023 Licensing Program Analyst (LPA) Lea Habtom met with Licensee, Teresa Mack, for the purpose of an unannounced required 1-year inspection. Licensee's assistant, adult daughter and under age volunteer were present in the home today. Licensee's adult daughter was volunteering for today's celebration. All individuals subject to criminal background review have obtained a criminal record clearance. There were 13 children present which consisted of 2 infants over 1, 8 preschool and 3 school age children being supervised by licensee and her assistant.

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 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. Stairs were barricaded to prevent access when children under 5 are present. Outdoor play space is fenced.

Licensee was reminded that all adults 18 and over living or working in the home, 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 reviewed children's files. A current roster is being maintained and fire and disaster drills are documented. The licensee'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 7/11/2024, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 10/12/2024

(Report continues LIC809-C)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MACK, TERESA
FACILITY NUMBER: 313623714
VISIT DATE: 08/09/2023
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LPA observed two play yards at the facility. Play yards were 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.

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

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided an updated Plan of Operation that includes 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

Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, regulations, current forms, Provider Information Notices (PINs), and to subscribe to quarterly updates

No deficiencies cited today. Exit interview conducted and report was reviewed with the licensee Teresa Mack. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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