<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415698
Report Date: 08/12/2021
Date Signed: 08/12/2021 03:43:10 PM

Document Has Been Signed on 08/12/2021 03:43 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:GEORGE, ASHLEYFACILITY NUMBER:
444415698
ADMINISTRATOR:GEORGE, ASHLEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 896-5570
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ashley GeorgeTIME COMPLETED:
04:00 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
Licensing Program Analyst (LPA) Goodell met with licensee, Ashley George, for the purpose of an Unannounced Annual Random Inspection. Hours of operation are Monday- Friday, 8:30pm- 4:30pm. During inspection LPA arrived during nap time and observed 3 children present. LPA also observed two assistants present. All individuals subject to criminal background review have obtained a criminal record clearance.

Inspection was conducted in all areas accessible to children both indoor and out. Off-limits areas include garage and upstairs above main house. LPA verified current phone number and email are current. LPA also observed a 2A10BC 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, and knives are stored inaccessible to children.

Children's records were reviewed. Individual Infant Sleeping Plan (LIC9227) and sleeping log for infants were discussed. LPA reviewed staff files and observed proof of AB1207 Mandated Reporter Training Certificate not available in staff files for staff #1 and #2 which poses a potential risk to children in care. LPA also observed fire drill log and children roster maintained. Licensee stated proof of certificate will be submitted to LPA. Preventative health training, current pediatric CPR and first aid certification was verified and expired on 1/20/2018 which poses a potential risk to children in care. Licensee stated proof of current CPR and 1st Aide will be submitted to LPA.
Report continues on LIC809-C
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GEORGE, ASHLEY
FACILITY NUMBER: 444415698
VISIT DATE: 08/12/2021
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
26
27
28
29
30
31
32
The Effects of Lead Exposure brochure was issued and discussed. All Inclined sleepers are prohibited per: PIN 19-16-CCP was issued and discussed. Lead Flyer Requirement and Safe Sleep Awareness was 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.

Title 22 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. Appeal Rights also issued and discussed.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/12/2021 03:43 PM - It Cannot Be Edited


Created By: Kristal Goodell On 08/12/2021 at 03:13 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: GEORGE, ASHLEY
FACILITY NUMBER: 444415698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
HSC
1596.8662(b)(1)

1
2
3
4
5
6
7
Administration of Child Day Care Licensing. 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
1
2
3
4
5
6
7
Licensee stated proof will be submitted to LPA by 8/27/21.
8
9
10
11
12
13
14
(a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. LPA reviewed staff files and observed proof of AB1207 Mandated Reporter Training Certificate not available in staff files for staff #1 and #2 which poses a potential risk to children in care.
8
9
10
11
12
13
14
Type B
09/10/2021
Section Cited
CCR102416(c)

1
2
3
4
5
6
7
Personnel Requirements. The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. LPA observed expired CPR/1st Aide which poses potential risk to children in care.
1
2
3
4
5
6
7
Licensee stated proof of current will be submitted to LPA by 9/10/21.

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3