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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625856
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:16:16 AM

Document Has Been Signed on 06/12/2024 11:16 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:DAVIS, TRACEYFACILITY NUMBER:
343625856
ADMINISTRATOR/
DIRECTOR:		DAVIS, TRACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 208-5843
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/12/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Tracey DavisTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Loraine Perez and Tanya Washington arrived at the facility at approximately 9:00 AM and met with applicant, Tracey Davis for the purpose of a change of location inspection. Applicant is currently licensed under facility #343622767. No other adults or children were present during inspection. Applicant subject to criminal background review has obtained a criminal record clearance. Applicant states she plans to operate Monday-Friday from 6 AM to 11 PM.

A health and safety inspection were conducted inside and out. The single story home has a front yard, 3 bedrooms, 2 bathrooms, a living room, kitchen, covered car port, fenced backyard and fence side yard. The off-limits areas are the master bedroom/bathroom and fenced side yard. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors and a fire extinguisher were observed in the home. Preventative Health, current pediatric CPR and first aid training was verified and expires 5/2026. Applicant stated that there are no weapons in the home. The fireplace in the home was appropriately barricaded to prevent access by children. Supervision was discussed and applicant understands that children must be 100% supervised in unfenced yards. Immediate Civil Penalty regulation and deficiencies were reviewed.

Because the applicant, leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149) to operate at a large capacity.

LPA discussed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: DAVIS, TRACEY
FACILITY NUMBER: 343625856
VISIT DATE: 06/12/2024
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LPA consulted applicant regarding the following topics; Type A vs. Type B deficiencies, complaints, LPA’s right to interview children without parental consent, civil penalties, incidental medical services, placement of detergents, placement of poisons, placement of medicines, announced vs. unannounced inspections, posting requirements, unusual incident reports, On-limits vs. Off-limit areas, licensing file management, fire drills, 80% supervision, 100% supervision, fingerprint clearances, advertising, mandated reporting, best practices, and applicant’s responsibility to stay up to date on new law and regulations.

LPA consulted the applicant regarding personal rights. Applicant understands that corporal, physical and/or unusual forms of punishment is never allowed toward day care children or their own children during day care hours.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current regarding new regulations.

LPA advised applicant to sign up for the quarterly updates provided by the Childcare Advocates Program. LPA provided the link https://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the licensee to sign up for the updates.

LPA discussed the safe sleep regulations with applicant 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 applicant 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 (IMS) policy was discussed. 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) or (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.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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: DAVIS, TRACEY
FACILITY NUMBER: 343625856
VISIT DATE: 06/12/2024
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Family Child Care Homes On this date, 06/04/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Facility remains pending Licensing Program Manager approval for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home. Exit interview conducted and report was reviewed with the applicant Tracey Davis.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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