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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010117
Report Date: 09/28/2021
Date Signed: 09/28/2021 03:21:16 PM

Document Has Been Signed on 09/28/2021 03:21 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HULTQUIST, ANJA FCCHFACILITY NUMBER:
493010117
ADMINISTRATOR:HULTQUIST, ANJAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 776-7198
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/28/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anja HultquistTIME COMPLETED:
03:30 PM
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A prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Glenn Ouye. The applicant is requesting a license for a capacity of 14 children. The applicant is a qualified preschool teacher and a fire clearance was approved on 9/28/2021. Services will be available Monday - Friday, 7:30AM to 5:30PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a three bedroom/two bathroom, single level home. There is one adult living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.

The floor and yard plans are verified. The children will have access to the living room, hall bathroom and two bedrooms. The "off limits" areas include the master bedroom. The master bedroom is made inaccessible with a door knob slip cover. The kitchen is made inaccessible with a child safety gate. 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. There were no firearms and ammunition in the home at the time of this inspection. Poisons are stored in stored a locked shed in an off-limits area of the home's backyard. 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 2A10BC. There is no fireplace or wood stove in the home. The facility has an open yard in front of the home which will be used as an outdoor activity area. It is currently not fenced but the applicant will provide supervision. A fence will be installed at a later date. There is no spa, pool, pond, or fountain on the premises.

Continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HULTQUIST, ANJA FCCH
FACILITY NUMBER: 493010117
VISIT DATE: 09/28/2021
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Incidental Medical Service (IMS) regulations were reviewed with the applicant. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department.

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 applicant will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. The applicant 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 applicant 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 applicant 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. Smoking is prohibited at all times in any area where child care is provided. The applicant 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/. Infant safe sleep regulations and the effects of lead exposure were discussed with the applicant. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

This home is approved for licensure as a small FCCH effective today's date.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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