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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415068
Report Date: 08/18/2021
Date Signed: 08/18/2021 01:06:15 PM

Document Has Been Signed on 08/18/2021 01:06 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SMITH, ANNIKAFACILITY NUMBER:
444415068
ADMINISTRATOR:SMITH, ANNIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 566-5587
CITY:BEN LOMONDSTATE: CAZIP CODE:
95005
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Smith, AnnikaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Goodell met with licensee's assistant Sue Lotz, for the purpose of an Unannounced Annual Random Inspection. During inspection LPA spoke to licensee Annika Smith via phone call. LPA observed 12 children present with two assistance. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation are Monday- Friday, 9:00 am- 1:00pm.

Inspection was conducted in all areas accessible to children which included TV room located in main house, restroom, daycare area that is separate from main house, outdoor area and daycare restroom located in converted garage. Off-limits areas include converted garage and areas in main house which include three bedrooms, office, living room, kitchen, dining room, upstairs master bedroom and master bathroom. LPA verified current phone number and email are current. LPA also observed a 3A40BC fire extinguisher, smoke and carbon monoxide detectors. No weapons, bodies of water or poisons in the home. Licensee acknowledged that 100% supervision is required in unfenced area. LPA observed cleaning compounds, medication and knives are stored inaccessible to children.

Children's records were reviewed. LPA observed fire drill log maintained. LPA also reviewed staff files and observed proof of staff immunization for staff #2 not on file which poses an potential risk to children in care. LPA also observed proof of Mandated Reporter Training AB1207 not on file for staff #1, #2 and licensee which pose a potential risk to children in care. Staff and licensee acknowledged requirement and stated proof will be submit to LPA by 9/10/21. Preventative health training, current pediatric CPR and first aid certification was verified and expires 2/2022.
Report continues on LIC809-C
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SMITH, ANNIKA
FACILITY NUMBER: 444415068
VISIT DATE: 08/18/2021
NARRATIVE
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The Effects of Lead Exposure brochure was issued and discussed. Lead Flyer Requirement and Safe Sleep Awareness were issued discussed. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, forms, self-assessment guides, legislation and regulation information. PIN 21-08-CCP and COVID-19 UPDATE Guidance: Child Care Programs and Providers were discussed.

Deficiencies cited. LPAs reviewed report with the licensee and provided copies. An exist interview was conducted. The Notice of Site Visit issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2021 01:06 PM - It Cannot Be Edited


Created By: Kristal Goodell On 08/18/2021 at 12:33 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SMITH, ANNIKA
FACILITY NUMBER: 444415068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
HSC
1597.622(a)(1)

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Employees or volunteers at family day care home; immunization requirements; records; exemptions. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination
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Licensee and staff acknowledged requirement and stated proof will be submitted to LPA via email by 9/10/21 via email.
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between August 1 and December 1 of each year.

During file staff file review LPA Goodell observed proof of immunizations not available in file for staff #2 which poses a potential risk to children in care.
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Type B
09/10/2021
Section Cited
HSC1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years
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Licensee and staff acknowledged requirement and stated proof will be submitted to LPA via email by 9/10/21 via email.
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following the date on which he or she completed the initial mandated reporter training.
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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