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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384003093
Report Date: 08/20/2021
Date Signed: 08/20/2021 11:28:42 AM

Document Has Been Signed on 08/20/2021 11:28 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WYNN, LAKEYAFACILITY NUMBER:
384003093
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lakeya WynnTIME COMPLETED:
11:40 AM
NARRATIVE
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On August 20, 2021, at approximately 10:15am, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Required-1 Year Visit to this family child care home and met with Licensee Lakeya Wynn. Purpose of visit was explained. Present during the visit were Licensee caring for 2 children, one is an infant. All required posting documents are posted and visible.

Day Care Areas is the living room and bathroom upstair. Off Limit Areas are the upstair two bedrooms, garage and the backyard. Completed Child Abuse Mandated Reporter Training is on file.Required Immunizations: Influenzas, Pertussis and Measles are on file.

LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care.

At approximately 10:45 am LPA reviewed children's record and found children's files are incomplete. The deficiency of not having complete children's files was being cited based on LPA Ly’s observation in accordance with the California Code of Regulations, Title 22, Type B deficiency issued on this day see LIC 809D.

CONTINUED>>>
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: WYNN, LAKEYA
FACILITY NUMBER: 384003093
VISIT DATE: 08/20/2021
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****This family child care home does not provide Incidental medical 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.

Licensee was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018 all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.


An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Licensee. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of these reports.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2021 11:28 AM - It Cannot Be Edited


Created By: Winnie Ly On 08/20/2021 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: WYNN, LAKEYA
FACILITY NUMBER: 384003093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
102421

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102421: Child's Records – children’s records are incomplete. This requirement is not met as evidence by:


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Licensee to have a complete file for each child and maintain the child's file for 3 years after child leaves facility.

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Based on LPA review of children files, files are found to be incomplete. Files do no have any of Licensing Required Documentations. This is a potential health and safety hazard.
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A return visit will be conducted to verify correction by 09/03/2021

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
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