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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620691
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:55:23 PM

Document Has Been Signed on 08/10/2023 01:55 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARTIN, SHALESEFACILITY NUMBER:
343620691
ADMINISTRATOR:SHALESE MARTINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 416-5409
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Shalese MartinTIME COMPLETED:
03:00 PM
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On 08/10/2023, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Shalese Martin (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA observed 3 infants, 1 preschool aged child, and 4 school aged children being supervised by L1 and an adult Aide. LPA accessed Guardian to determine that all required adults were background cleared and associated to the license. L1 stated that the Aide resides in the FCCH. LPA toured the areas of the FCCH that are accessible to children in care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include the laundry room, entire upstairs, and garage. L1 acknowledged that children may never enter these OFF-limits areas. L1 reports her hours of operation to be 7 days per week from 4:00 am until 3:00 am with occasional over night care.

LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA reviewed the children’s files for those who were in attendance. LPA reviewed the adult’s files and immunizations. LPA reviewed the Facility’s Roster and observed the Fire Drill log to ensure that drills are conducted at least once every 6 months. A functioning smoke detector and carbon monoxide detector was observed on the first floor and tested. LPA observed cleaners stored on shelves that are out of reach to the children in care and also under the kitchen sink behind a cabinet door with a child safety lock. LPA observed knives stored on a shelf that is above the oven and out of reach to children in care. The fireplace in the living room was observed to have a glass barricade; L1 stated that the fireplace will not be used during operational hours. LPA observed a baby-gate barricading the stairway to make the stairs inaccessible to children. LPA observed a 2A10BC fire extinguisher that appeared to be in the green zone. L1 stated that she owns a first-aid kit which is stored in the bathroom and another outside. Toys appeared to be safe and in good supply. LPA did not observe any pool, spa nor water feature.

Continued on 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARTIN, SHALESE
FACILITY NUMBER: 343620691
VISIT DATE: 08/10/2023
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LPA walked the perimeter of the backyard and ensured the stability of the surrounding fence. LPA observed a play structure in the back yard that appeared to be in working condition and was cushioned by wood chips. L1 stated there are no firearms in the FCCH. L1 stated that she owns 1 dog.

LPA discussed Mandated Reporter Training with L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. L1 has a current Mandated Reporter Training Certificate which will expire on 08/08/2025. Current Pediatric CPR and First Aid training was also verified by LPA and will expire on 06/04/2024.

LPA discussed the Safe Sleep Regulations with L1 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 L1 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 that s/he register all infant devices with the CPSC to be notified of any recalls on purchased equipment.

Incidental Medical Services (IMS) policy was discussed with L1. LPA provided information on IMS plan. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information through this communication platform. To receive important licensed related information, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. Continued on LIC 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARTIN, SHALESE
FACILITY NUMBER: 343620691
VISIT DATE: 08/10/2023
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L1 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. L1 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 7 days to remain in compliance. L1 understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years.



To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

NO Title 22 Deficiencies were observed in the areas that were evaluated today on 08/10/2023. An exit interview was conducted, and the report was reviewed with L1. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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