426216598-5-26-2023-17-CC-EBAY-CS7TYK-20230526150851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426216598
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:11:26 PM

Document Has Been Signed on 05/26/2023 03:11 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	ADAMS FCC		FACILITY NUMBER:	426216598
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 1	DATE:	05/26/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Laura Paige		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/26/23, at 12:45 AM, Licensing Program Analyst (LPA) Elvin Baddley conducted an announced Prelicense Inspection of the abovementioned home and met with Applicant Laura Paige. LPA informed Applicant of the nature and purpose of the inspection. Applicant informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from 12:00 AM--11:59 PM, Monday- Thursday, Friday 3:00 PM- 11:59 PM, Saturday and Sunday 12:00 AM- 11:59 PM. Applicant also intends to care for children 6 months of age to 12 years of age. LPA notes one child (biological) is present at the time of the inspection. LPA, in the company of Applicant, toured the interior and exterior of the home in its entirety. The home is a three bedroom, two bathroom single story dwelling. The home's living room, dining room, guest bedrooms (2), hallway bathroom and backyard will be used for child care services, while the remainder of the home will be excluded. LPA observed a child safety gates at the entry of the kitchen. LPA observed the home to be clean and orderly. The home has spacing and ventilation for children in care. The home has a fireplace in the living room which is screen by glass. The bathroom to be used for children in care is observed to be clean and free of toxins. Medication and cleaning compounds are secured in a cabinet in the kitchen area. Sharps are located in an elevated cabinet in the kitchen. LPA observed a fire extinguisher (2A10BC) in the home which was purchased 12/22/22. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has both smoke and carbon monoxide detectors. A smoke detector was tested at 2:09 PM and found to be operable. The carbon monoxide detector is active and did not have a testing function. The backyard is enclosed by wooden fencing and the footing in the area is varied. The fences entry/exit gates are secured. The backyard area is partitioned to have a dog run area which is enclosed. A section of the (CONT. LIC 809-C, Page 2)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ADAMS FCC	FACILITY NUMBER: 426216598
	VISIT DATE: 05/26/2023

NARRATIVE

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backyard contains an adult trampoline. Applicant was informed to keep the trampoline secure and to ensure the trampoline is not used by children in care. Toy, furniture and play equipment in the outdoor area is age appropriate. LPA observed no bodies of water on site.

LPA's record review revealed Applicants' Mandated Reporter training was completed on 1/18/23 (expiration 1/18/25), and Pediatric CPR/First Aid (EMSA approved) was completed on 1/30/23 (expiration 1/30/25). Applicant completed Preventative Health Training on 1/12/23. LPA reminded Applicant of obligation to maintain current training and certifications. LPA reviewed Applicant's control of property document (Lease Agreement). Applicant does not have liability insurance for the home as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282). Applicant informed LPA firearms and ammunition are on site. LPA reviewed storage of the aforementioned noted firearms and ammunition are stored separately. LPA observed a dog on site. LPA reviewed vaccination records for the dog and notes the records are current.

LPAs reviewed 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.

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 Homes and the ADA, available at: http://www.ada.gov/childqanda.htm

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

(CONT. LIC 809-C, Page 3)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ADAMS FCC	FACILITY NUMBER: 426216598
	VISIT DATE: 05/26/2023

NARRATIVE

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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.

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 communication platform.

To receive important licensed related information to licensed facilities, 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.

Exit interview conducted and report was reviewed with the Applicant Laura Paige. The home meets Title 22 Division 12 requirements of a Small FCCH License (8). Effective date of license will be noted as the present, 5/26/23.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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