313624911-6-27-2023-03-CC-MGAO-CT7NCF-20230627102040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313624911
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:20:46 AM

Document Has Been Signed on 06/27/2023 10:20 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	EKSTEDT, MICHELLE		FACILITY NUMBER:	313624911
ADMINISTRATOR:	EKSTEDT		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 483-6878
CITY:	MEADOW VISTA	STATE: CA	ZIP CODE:	95722
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	06/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michelle Ekstedt		TIME COMPLETED:	10:30 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	At 9:00 am, Licensing Program Analyst (LPA) Matthew Gallo met with applicant Michelle Ekstedt for the purpose of a prelicensing inspection. Applicant has requested a Large Family Childcare Home License to serve up to fourteen children. The facility is a one story home consisting of a living room, kitchen, dining area, play room, nap room, hall bathroom, office, master bedroom/bath, and garage. Off limits areas will include master bedroom/bath, office, and garage. Hours of operation are 7:30AM-5:30PM, Monday thru Friday. Applicant understands she must be present at the facility for 80% of operating hours. Applicant understands that their own children under 10 years old count toward the ratio. All individuals subject to criminal background review have obtained a criminal record clearance. 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 and Applicant toured the entire facility. LPA observed functioning smoke and carbon monoxide detectors, and a 2A10-BC fire extinguisher. LPA reviewed the required postings with applicant. Cleaning materials, hazardous items, and medications are all stored inaccessible to children. There are no bodies of water on the property. Applicant understands that an inspection by the department must be made prior to making an off limits area on limits. Applicant stated that there are no firearms in the facility, LPA observed poisons to be stored under lock. Stairs are properly fenced. There are fireplaces in the living room and play room that are properly barricaded. Report Continues on 809-C

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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: EKSTEDT, MICHELLE	FACILITY NUMBER: 313624911
	VISIT DATE: 06/27/2023

NARRATIVE

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Applicant provided proof of control of property. Applicant understands that until a liability insurance coverage in the amount of $300,000 is provided, the affidavit form LIC282 form will be used.

Applicant submitted proof of current CPR/First Aid, completion of Preventative Health and Safety Training, and Mandated Reporter certificate. Applicant understands the CPR and Mandated Reporter training must be renewed every two years.

LPA reviewed Safe Sleep regulations and provided the 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 was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417 and 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) 513-0301 (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.ht

This facility evaluation report was reviewed and discussed with the applicant. LPA discussed supervision, personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

Effective today, June 27, 2023, the facility is approved for a Large Family Child Care Home license for a capacity of 12 children with no more than 4 infants, or up to 14 children with no more than 3 infants, 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: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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