574500303-12-22-2022-53-CC-SMAY-CMCTW8-20221222140506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 574500303
Report Date: 12/22/2022
Date Signed: 12/22/2022 02:05:16 PM

Document Has Been Signed on 12/22/2022 02:05 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	HORN, JOHANNA		FACILITY NUMBER:	574500303
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 3	DATE:	12/22/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Johanna Horn		TIME COMPLETED:	02:15 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) Salene Mayberry met with Licensee, Johanna Horn for the purpose of conducting a case management inspection to increase the facility capacity. Licensee applied to change from a Small Family Child Care Home to a Large Family Child Care Home on 9/15/2022. A Fire clearance was granted by Davis Fire Department on 12/15/2022. LPA observed three children present in the home with Licensee. LPA verified the annual fees are current. Licensee’s days and hours of operation are Monday through Friday 8:30 am to 3:30 pm. All adults have criminal record clearances. Licensee was reminded that all adults 18 and over living or working in the home, 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. LPA and Licensee toured the single-story two bedroom, one bathroom home inside and out. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. All areas are on-limits. LPA verified toxic and hazardous items were inaccessible to children in care. LPA also verified the facility maintains a working phone, has a 3A40BC fire extinguisher, and functioning combined smoke and carbon monoxide detector. LPA observed two first aid kits which are stored in the hallway closet and the diaper bag. Licensee stated there are no weapons in the home. Current in person EMSA CPR and First Aid certification was verified and expires 08/2024. AB1207 Mandated Reporter Training was also verified and expires 10/06/2024. Report continued on LIC809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: HORN, JOHANNA	FACILITY NUMBER: 574500303
	VISIT DATE: 12/22/2022

NARRATIVE

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The outdoor play space includes a climbing structure, planter beds and a sand box. LPA observed a locked shed in the backyard. The backyard is not completely enclosed, and Licensee understands that when children are present in the backyard there must be 100% supervision.

LPA did not observe a signed Property Owner/Landlord Consent form (LIC9149). Licensee acknowledged that she understands that she may not care for more than 12 children at one time without the approved Property Owner/Landlord consent.

LPA reviewed with and provided Licensee a copy of Forms/Records to Keep in Your Family Child Care Homes, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted (LIC311D).
Licensee currently does not have any children enrolled that require Incidental Medical Services (IMS). Licensee understands that if in the future any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

Information regarding ADA was provided to Licensee: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(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 discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at 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.

Licensee was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Report continued on LIC809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: HORN, JOHANNA	FACILITY NUMBER: 574500303
	VISIT DATE: 12/22/2022

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An exit interview conducted, and the report was reviewed with Licensee. LPA also provided Licensee with a copy of the report.

Effective today 12/22/22, the facility is approved for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.

LPA posted a Notice of Site Visit and confirmed that Licensee understands it must remain posted for 30 days. A failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC809 (FAS) - (06/04)

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