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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409121
Report Date: 07/09/2021
Date Signed: 07/09/2021 09:46:35 AM

Document Has Been Signed on 07/09/2021 09:46 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JOHNSON, SAMANTHAFACILITY NUMBER:
073409121
ADMINISTRATOR:JOHNSON, SAMANTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 597-2848
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/09/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Samantha JohnsonTIME COMPLETED:
10:00 AM
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On 7/9/21 at 9:15 AM Licensing Program Analysts (LPAs) Monica Mathur and Michelle Sutton conducted an announced Case Management inspection at Samantha Johnson's family day care. LPAs met with Licensee, Samantha. Present in the home were Licensee, Helper and 5 day care children (1 infant, 4 preschool age). Facility is in ratio compliance today.

Licensee wants to add the Master Bedroom to the on limit area as a nap room for children. LPAs inspected the room. It is safe, free of hazards and dangerous items are stored out of reach from children. Approval is granted for use of Master Bedroom for day care. An updated facility sketch is on file. The IN USE AREAS in the home are:
Play Room, Living Room, BedroomS 1, 2, 3, Bathroom, Kitchen, Backyard.

At 9:45 AM exit interview was conducted with Licensee where this report was reviewed and signatures obtained acknowledging receipt of documents.

A NOTICE OF SITE VISIT IS ISSUED AND TO BE POSTED IN PUBLIC VIEW FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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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