073409121-11-15-2021-02-CC-MMAR-C8SVMX-20211115153416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073409121
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:34:29 PM

Document Has Been Signed on 11/15/2021 03:34 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	JOHNSON, SAMANTHA		FACILITY NUMBER:	073409121
ADMINISTRATOR:	JOHNSON, SAMANTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 597-2848
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 11	DATE:	11/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Samantha Johnson		TIME COMPLETED:	03:45 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	On 11/15/21 at 1:30 pm Licensing Program Analysts (LPAs) Monica Mathur and Ashley Curry conducted an unannounced Annual/Random Inspection at Samantha Johnson's Family Day Care Home. LPA met with Licensee, Samantha and explained the purpose of today’s inspection. LPA was granted permission to enter the facility. Present in the home were Licensee, Assistant, spouse (also helper) and 11 day care children (2 infants, 9 preschool age). Facility is in compliance with required ratios today. Children were napping and later engaged in various activities under the supervision of the Licensee and Helper. Days and hours of operation are Monday - Friday from 7 am - 5 pm. All adults have Criminal Background Check Clearances, TB clearance and signed Criminal Record Statements LIC508 on file with Licensing Office. At 1:45 pm LPA conducted an inspection of the indoor and outdoor areas of the home with Licensee: INDOOR SPACE: In Use Areas: Living room, Family room, 3 Bedrooms, 1 Bathroom Off Limit Areas: Kitchen, Garage The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters in the home. There is a barricaded fireplace inside the home. There are no stairs inside the home. OUTDOOR SPACE: Off Limit Areas: Left & Right side yards The outdoor space and play equipment were observed to be maintained in safe condition and free of hazards. Heavy structure was secured to the ground. There is a large and small trampoline. Licensee was reminded to provide 100% supervision and follow the manufacturer's product use directions when using trampolines. The yard was fenced and there were no bodies of water.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JOHNSON, SAMANTHA	FACILITY NUMBER: 073409121
	VISIT DATE: 11/15/2021

NARRATIVE

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LPA observed a fully charged fire extinguisher and working smoke / carbon monoxide detectors. The Licensee states that she has a fire arm in the home. LPA observed it was stored as per CCLD requirements. There are 2 dogs in the home.. LPA reviewed a current Children Roster and obtained a copy. Last fire/disaster drill was completed on 9/9/21. All required postings including but not limited to Parent Rights Poster, Facility License, Emergency Disaster Plan were observed posted. The Licensee states that she does not transport children. Licensee states that she supplies snacks and meals to the children. Food storage area was observed to be clean and child cups, bowls and bottles were labeled with child’s name. LPA discussed Healthy Beverages Act with the Licensee. Day care home appeared to be free of flies, other insects, and rodents during today’s inspection.

FILE REVIEW:
At 2:15 pm Children's files were reviewed and contained all required Licensing forms and records including but not limited to Receipt for Parents' Rights, Immunization record, Identification & Emergency Information, Consent for Medical Treatment, Parent Notification for Additional Children in Care, Affidavit Regarding Liability Insurance,Health History.
Licensee and Assistant files contained Criminal Record and Child Abuse Index Clearance, TB clearance, Statement Acknowledging Requirement to Report Suspected Child Abuse, Employee Rights, Immunizations for Measles, Pertussis, Flu and required Mandated Reporter Training per AB1207. Licensee's certifications for CPR and First Aid are current and expire on 11/29/22.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times. The Licensee understands her capacity options and that she cannot have more than 14 children in the home at any time without at least two qualified adults present. Licensee also understands that she must comply with the ratio and capacity requirements of the Small Family Child Care Home license whenever she or a qualified adult is alone with the children.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JOHNSON, SAMANTHA	FACILITY NUMBER: 073409121
	VISIT DATE: 11/15/2021

NARRATIVE

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LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Individual Medical Services (IMS) policy was discussed. When any changes to the IMS plan is made, an updated 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)/ (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.

In the areas that were evaluated, no regulatory violations were observed.
At 3:20 pm exit Interview was conducted, where this report was reviewed and discussed with Licensee, A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED FOR 30 DAYS.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC809 (FAS) - (06/04)

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