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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010397
Report Date: 04/18/2023
Date Signed: 04/18/2023 09:54:32 AM

Document Has Been Signed on 04/18/2023 09:54 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WILBURN, LATASHA FCCHFACILITY NUMBER:
483010397
ADMINISTRATOR:WILBURN, LATASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 439-5048
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 1DATE:
04/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Licensee Latasha WilburnTIME COMPLETED:
10:00 AM
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A change of location inspection was conducted today by Licensing Program Analysts (LPA) Elpidia Hernandez Torres. The licensee was previously licensed at facility number 483009796. The licensee is requesting a license for a capacity of 14 children. Fire clearance was granted on 04/11/2023 from local fire department. Services will be available Monday - Friday, 07:00AM- -5:30PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a four bedroom/Three and half bathroom, dual level home. There is currently Five adults living in the home. Licensee 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.

The floor and yard plans are verified. The children will have access to the day care room, kitchen, dining room, family room, office and back yard. The "off limits" areas include the entire 2nd level and all its rooms, the mudroom, the garage, and the closet under the stairs. These areas will be made inaccessible by door locks, latches, door knob covers, and/or child gates. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. The firearms and ammunition are locked and stored separately per regulation. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies will be maintained at the facility. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and a fire extinguisher rated at least 2-A 10:BC. The home's back yard is fully fenced and will be used for childcare. There is no spa, pool, pond, or fountain on the premises and none shall be added without prior approval from the Licensing agency. Incidental Medical Services regulations were reviewed with the licensee. The licensee understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department. Continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILBURN, LATASHA FCCH
FACILITY NUMBER: 483010397
VISIT DATE: 04/18/2023
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LPA reviewed with licensee 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. Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property or landlord notification/consent is on file. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times.

Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The licensee will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. The licensee shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The licensee understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The licensee clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged.

LPA discussed safe sleep regulations with licensee and the Child Care Licensing Safe Sleep web page https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

Smoking is prohibited at all times in any area where child care is provided. The licensee understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. The licensee understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. Exit interview conducted and report was reviewed with the licensee Latasha Wilburn.
continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILBURN, LATASHA FCCH
FACILITY NUMBER: 483010397
VISIT DATE: 04/18/2023
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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 license-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.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.



The change of location application has been approved effective today's date.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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