313623788-7-29-2021-03-CC-JMCN-C5DMYA-20210729100114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313623788
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:01:27 AM

Document Has Been Signed on 07/29/2021 10:01 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:	ROBERTS, MELISSA		FACILITY NUMBER:	313623788
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	07/29/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Melissa Roberts		TIME COMPLETED:	09:30 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	On July 29^th, 2021 Licensing Program Analysts (LPA) Jeremey McClain conducted a Pre-Licensing inspection with applicant Melissa Roberts. Applicant is applying for a Small Family Child Care License. A health and safety inspection of the home was conducted. All individuals subject to criminal background review have obtained a criminal record clearance. The two-story home has an unfenced front yard, three bedrooms, two and half bathrooms, a living room, dining room, kitchen, garage, and fenced backyard. The off-limits areas in the home will be the upstairs, the garage, the right side of the backyard, and the laundry room. Off-limits areas will remain inaccessible to children by closed doors and or supervision. LPA advised applicant that 100% supervision is required for areas outside that are unfenced. The fireplace in the living room is appropriately barricaded to prevent access by children. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors were observed. Applicant provided proof of purchase of a 2A10BC fire extinguisher. Current pediatric CPR and first aid training was verified and expires 5/16/2021. Applicant stated there are no weapons in the home. No standing bodies of water were observed at the home. Applicant was encouraged to maintain supervision at all times. Immediate Civil Penalty regulation deficiencies were reviewed. Applicant has provided proof of Immunization for Pertussis, Measles and Influenza. Tuberculosis clearances for all adults in the home have been provided. Applicant has completed the required AB1207 Mandated Reporter training as of 04/12/2021. Applicant understands that the training must be completed once every two years, and that Mandated Reporter trainings offered outside of http://childcare.mandatedreporterca.com/ , must be approved by the department. REPORT CONTINUED ON THE FOLLOWING PAGE...

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: ROBERTS, MELISSA	FACILITY NUMBER: 313623788
	VISIT DATE: 07/29/2021

NARRATIVE

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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that any assistants for the childcare must also obtain the following: EMSA certified CPR and first aid training, immunizations for measles Pertussis and Influenza, complete AB1207Mandated Reporter Training, and complete eight hours of preventative health and safety training.

Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if they move and want to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area.

Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years after the child is no longer enrolled. Applicant understands that their License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home.
CCR 102425, as well as the department’s website for Safe Sleep Resources:
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

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

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed.

Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.
REPORT CONTINUED ON THE FOLLOWING PAGE...

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: ROBERTS, MELISSA	FACILITY NUMBER: 313623788
	VISIT DATE: 07/29/2021

NARRATIVE

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LPAs also provided the childcare advocates e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov

As of today, July 29^th, 2021, the applicant is approved for a Provisional Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, with 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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