444417882-8-28-2024-07-CC-MKAR-D8KPYZ-20240828114447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444417882
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:45:01 AM

Document Has Been Signed on 08/28/2024 11:45 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HAMBLIN MATHEWS, MICHELLE		FACILITY NUMBER:	444417882
ADMINISTRATOR/ DIRECTOR:	MICHELLE HAMBLIN MATHEWS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 251-0921
CITY:	BOULDER CREEK	STATE: CA	ZIP CODE:	95006
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/28/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Michelle Hamblin Mathews		TIME VISIT/ INSPECTION COMPLETED:	12:05 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) Mandeep Kaur conducted an announced prelicensing inspection. LPA met with Applicant Michelle Hamblin Mathews and explained the reason for the inspection. Purpose of this inspection: Applicant applied for a Large Family Child Care Home (FCCH) license. Applicant has previous working experience with children and proof of the experience is in file. A fire Clearance for Large Family Child Care Home was granted on 06/19/2024. The Applicant, Applicant's husband and Applicant's both parents are the only adults residing in the home. Applicant has two minor sons also residing in the home. The hours of operation will be Monday through Thursday 9AM to 1:00 PM. Applicant does plan on obtaining liability insurance for the day care. Applicant understands that parents will need to fill out the Affidavit Regarding Liability Insurance (LIC 282) if she does not plan on obtaining liability insurance for the day care. Applicant has a valid CPR/1st Aid, which expires on 05/2026. Applicant's Preventive Health and Safety certificate and Mandated Reporter training certificate are on file. Applicant completed the Preventative health and Safety training on 05/04/2024 and Mandated Reporter training on 05/17/2024. LPA reminded Applicant that the Mandated Reporter training and CPR/1st Aid requires renewal every two years. Applicant's immunization records for TB, measles, pertussis, and influenza are also on file. Applicant provided proof of control of property (Copy of Lease agreement on file). Because the Applicant rents/leases the home, proof of landlord notification is required. LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the Applicant confirms was provided to the property owner/landlord. The Applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149) and LIC 9149 is on file. LPA toured the inside and outside of the home with Applicant. Applicant resides in a single story single family home. Off limit area in the home includes: 2 bedrooms, 1 bathroom, and laundry room. Off limit area: outdoor: outside of the fenced school area, and shed. LPA observed the barricaded stairs to the entrance of the home. Continue on 809-C

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAMBLIN MATHEWS, MICHELLE	FACILITY NUMBER: 444417882
	VISIT DATE: 08/28/2024

NARRATIVE

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**Continuation from 809**

Applicant was advised to keep the sharp items and breakable glass items inaccessible to the children in the kitchen including coffee maker as kitchen is on limit area in the home.

Applicant will be providing morning snacks to the children. Healthy beverages requirements were discussed with the applicant and copy is provided to the applicant..

LPA advised the applicant that children need to be supervised at all times.

The Applicant has a valid phone in the home. There is sufficient toys, supplies and equipment for the day care children indoors and outdoors.

LPA observed a fully charged fire extinguisher (2A10ABC), working combo smoke & carbon monoxide
detectors, no bodies of water, and fenced backyard and frontyard. Applicant states that she has two cats, one pig, one turtle and pets will stay in offlimit area. Applicant stated that there are no weapons/ammunition in the home.

All disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible. There were no baby walkers or bouncers observed in the on-limit areas for the children. Applicant understands that baby walkers or other similar items are not permitted for the children. LPA reminded Applicant that fire/disaster drill need to be conducted every six (6) months and documented.

Forms of discipline to be used by Applicant: talk to the children. Applicant understands that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed.

**Continue of next page: 890-C**

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAMBLIN MATHEWS, MICHELLE	FACILITY NUMBER: 444417882
	VISIT DATE: 08/28/2024

NARRATIVE

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**Continuation from 809-C**

Applicant has applied for Large family child care home license for the age group of 2 years to 17 years old. Applicant has her own infant child. 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 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.

Applicant states that she may administer medication once she has children in care. Applicant states that a
child will be isolated in the hallway in front of a bedroom adjacent to the school room if necessary due to illness or communicable disease. Applicant has a First Aid kit with a touchless thermometer in the home.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (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.

LPA 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. Entrance Checklist was provided to the applicant.

One(A1) of the four adults, who resides in the home, needs to clear criminal record clearance. Three of the four adults have cleared criminal record clearance, child abuse index, and TB. One adult(A1) has cleared child abuse index and TB test. 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

**Continue on next page 809-C**

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HAMBLIN MATHEWS, MICHELLE	FACILITY NUMBER: 444417882
	VISIT DATE: 08/28/2024

NARRATIVE

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**Continuation from 809-C**

On this date, 05/29/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families
obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs)
throughout California.

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 platforms.To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://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 Applicant Michelle Hamblin Mathews. LPA advised Applicant that Large Family Child Care Home license will be issued upon completion of the following:

1. Fingerprint clearance for Adult (A1).
2. Licensing Program Manager (LPM) review and approval.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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