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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625063
Report Date: 07/05/2023
Date Signed: 07/06/2023 10:40:24 AM

Document Has Been Signed on 07/06/2023 10:40 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:SMITH, ANNALISAFACILITY NUMBER:
343625063
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Annalisa SmithTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with applicant, Annalisa Smith, for a pre-licensing inspection at the facility. Applicant was licensed (343623809) previously at different location. Applicant applied for a new license due to change of location. At new location, applicant lives in single story home. All the adults living in the house has criminal background clearance on file. Per applicant, applicant purchased the property. Child care will be provided in areas: Living room, Dining area, Kitchen, Bathroom next to Laundry area, Bedroom next to laundry area, Hallway, Bathroom in hallway Bedroom next to Bathroom in the hallway and Backyard. Off limit areas: Master bedroom, Bedroom next entrance and the storage shed in the back yard. All off limits areas must remain made inaccessible to children. Applicant was notified that prior to use of any off limits area, the department must be notified.

LPA Singh inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All of the toxic or dangerous materials are stored in off limit areas. The house has a working telephone, fully charged fire extinguisher, carbon monoxide detector and smoke detector. There is first aid kit available. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. All of the unused electrical outlets have child protective covers installed.

Applicant is informed all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

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SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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: SMITH, ANNALISA
FACILITY NUMBER: 343625063
VISIT DATE: 07/05/2023
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Applicant has record of all the required immunization, CPR valid until October 2024. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. Smoking is prohibited in family child care homes. Applicant has the Mandated reporter training completion certificate on file. Per certificate, the training is valid until October 10, 2024.

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

The applicant is encouraged to frequently visit website at www.cdss.ca.gov http://www.ccld.ca.gov/for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

During today's inspection, LPA did not observe any hazard in the house. The house meets the requirements for the license. Therefore, the applicant will be granted the license for Small Family Child Care Home with maximum capacity of eight children in care.

Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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