Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093617355
Report Date: 11/12/2019
Date Signed: 11/12/2019 12:50:13 PM

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:NORDBY, TRACY A.FACILITY NUMBER:
093617355
ADMINISTRATOR:NORDBY, TRACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 919-6466
CITY:GEORGETOWNSTATE: CAZIP CODE:
95634
CAPACITY:14CENSUS: 12DATE:
11/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:TIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Pascual and Kelly met with licensee for the purpose of a random inspection. All individuals subject to criminal background review have obtained a criminal record clearance.
There were 12 day care children in care at time of inspection, licensee's assistant was also present.

Off-limit areas: Backyard, downstairs basement, all bedrooms, decking and kitchen. Licensee used the front yard for the children.
Today, the home was inspected inside and out and the following was observed by LPA:
-Knives, medications, first aid kit, and cleaning compounds were inaccessible to the children.
-LPA observed a working Smoke, and a Carbon Monoxide detectors, and a fully charged 3A40BC fire extinguisher
-Current CPR/First Aid certificate.
-Backyard is fenced, free from apparent safety hazards, however there is a in-ground pool, with 5ft fence and a self closing and latching gate.
-The toys appear to be safe and in good condition
-All sharp knives are stored out of reach
-Licensee stated there are no firearms in the home
-All adults in the home are fingerprint cleared
-Cleaning compounds are stored out of reach of children
-The bathroom was free of any hazardous items
-Medication are out of reach of children
-Posted license, parents rights, and emergency disaster plan
-LPA reviewed children's record, roster and fire drills documentation
--LPA discussed and reviewed Health & Safety code: 1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions with licensee. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a 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 and the ADA, available at: http://www.ada.gov/childqanda.htm
-There is a working telephone in the home
-LPA did not observed children alone in parked cars
-Provided licensee with website www.ccld.ca.gov to obtain forms and Title 22 Regulations.

The facility was in compliance at time of inspection.


SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Socorro KellyTELEPHONE: (916)216-7792
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
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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