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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620691
Report Date: 09/01/2021
Date Signed: 09/01/2021 02:18:24 PM

Document Has Been Signed on 09/01/2021 02:18 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MARTIN, SHALESEFACILITY NUMBER:
343620691
ADMINISTRATOR:MARTIN, SHALESEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 416-5409
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/01/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Shalese MartinTIME COMPLETED:
02:25 PM
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On 09/01/2021 at 1:01 PM Licensing Program Analyst (LPA) Jeevun Birk-Miller and Cherry Nepomuceno met with Licensee, Shalese Martin for the purpose of an unannounced annual inspection. Today's census was four children in care. All individuals subject to criminal background review have obtained a criminal record clearance. The Licensee's adult children were also present.

A health and safety inspection was conducted in all areas accessible to children. The off-limits areas of the home are: laundry room, garage and entire upstairs. LPA observed the required postings, a working phone, 3A-40-BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. The facility does not have any bodies of water. Toxic and hazardous items are inaccessible to children.

Four children's file were observed. All children's files had Emergency Contact forms. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. The Licensee has current Pediatric CPR & First Aid which expires on 12/2021 and current Mandated Reporter Certificate which expires 05/2023. LPA observed that it was current for the Licensee's assistants as well.

This provider is currently not providing IMS services to children in care. 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.

Report continues on 809-C.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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: MARTIN, SHALESE
FACILITY NUMBER: 343620691
VISIT DATE: 09/01/2021
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LPA verified the annual fees are current. This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.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.

At this time no deficiencies were cited. An exit interview was conducted. A copy of this report was given to the Licensee to keep on file at the facility.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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