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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500495
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:04:35 PM

Document Has Been Signed on 10/21/2021 12:04 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:LINDSEY, KIMBERLYFACILITY NUMBER:
394500495
ADMINISTRATOR:LINDSEY, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 603-9832
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/21/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kimberly Lindsey TIME COMPLETED:
12:15 PM
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On October 21, 2021 Licensing Program Analyst (LPA) Stacey Williams met with Applicant Kimberly Lindsey for the purpose of a pre-licensing inspection. Criminal record clearances were verified.

LPA and Applicant toured the single story home. The facility consists of 3 bedrooms, 2-bathrooms, living room, dining room, kitchen, and garage. Off limit areas will be all bedrooms and the garage.

Applicant owns the home with her husband. A copy of control of property is on file. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. LPA provided blank forms required for staff records as well as for children's records including LIC 9227- Individual Infant Sleeping Plan. At the left entry of the facility, LPA observed a licensing document area where Parent's Rights form, Emergency Disaster, and the Facility Sketch is posted. This is the designated area where Licensing forms/posters will be placed for parental review. LPA and Applicant discussed Safe Sleep Regulations and Covid-19 Guidance for Childcare Providers. Applicant understands the smoking prohibition for childcare.

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

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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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: LINDSEY, KIMBERLY
FACILITY NUMBER: 394500495
VISIT DATE: 10/21/2021
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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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