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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300680
Report Date: 06/15/2023
Date Signed: 06/19/2023 09:05:15 AM

Document Has Been Signed on 06/19/2023 09:05 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:SHOULTS FAMILY CHILD CAREFACILITY NUMBER:
336300680
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
06/15/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Crystal Shoults
TIME COMPLETED:
09:15 AM
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The licensee has applied to increase her capacity to that of a Large Family Child Care Home. Present during this visit were. Licensing Program Analyst (LPA) James Wilkerson toured the facility, inside and out, records were reviewed, and the following was observed:

· Per licensee, off-limit areas include: Laundry Room, Garage and 2nd Floor.
· Normal hours of operation will be: Monday through Friday 7:00 am to 5:30 pm
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the licensee during this inspection.
· All hazardous items inaccessible
· Toxins locked
· No guns or weapons present as of this date. LICENSEE UNDERSTANDS ALL GUNS, WEAPONS AND AMMUNITION MUST BE KEY-LOCKED SEPARATELY AND MADE INACCESSIBLE PER TITLE 22 REGULATIONS.
· Stairs are barricaded
· Fireplace is barricaded
· Verification of control of property on file
· Property owner/landlord notification and consent on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights forms are posted
· Pediatric CPR and First Aid Card - expire on 12/11/24
· Health & Safety Certificate - completed on 12/21/22
· There are no bodies of water as of this date. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: SHOULTS FAMILY CHILD CARE
FACILITY NUMBER: 336300680
VISIT DATE: 06/15/2023
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·The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time.
· Current roster on file
· Documentation of fire drills on file - hasn't been operating for six months
· Children’s records are in complete
· Employee’s records are complete
· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed.
Resident and/or staff records reviewed on 06/16/23 indicate that all adults who require caregiver
background checks have received all required clearances or exemptions.
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov
· Facility is not currently providing IMS at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

· For more information on SIDS and Safe Sleep Environments, please visit:
California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Risk-of-SIDS-in-Early-Education-and-Child-Care
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: SHOULTS FAMILY CHILD CARE
FACILITY NUMBER: 336300680
VISIT DATE: 06/15/2023
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And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep

The following items were discussed with the licensee:

- Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov


- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited
- The applicant is urged visit the U.S. Consumer Product Safety Commission webpage at

- Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov.


- Please subscribe at www.childcareadvocatesprogram@dss.ca.gov to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. This website can also be accessed through www.ccld.ca.gov
- The Duty Officer is available to answer questions Monday – Friday at 1-844-LET-US-NO (1-844-538-8766).

The application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. As agreed upon by the licensee, all corrections are due within 30 days. If not received within 30 days from the date of this report, the application may be withdrawn and the license will remain a Small Family Child Care Home.


Appeal rights were provided and discussed.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: SHOULTS FAMILY CHILD CARE
FACILITY NUMBER: 336300680
VISIT DATE: 06/15/2023
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During the exit interview, the LICENSEE, Crystal Shoults confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and TB Screen and have your child submit for LIVESCAN background clearance. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit the LIC508, TB screening and obtain a background clearance through LIVESCAN.

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING.

THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC 9099D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT).



Fire Clearance granted on 05/24/23.

A copy of this report was provided to the applicant on this date and must be made available to the public upon request for the next 3 years.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: James Wilkerson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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