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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414402
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:12:25 AM

Document Has Been Signed on 08/19/2022 11:12 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:HOLLAND, SUSIEFACILITY NUMBER:
013414402
ADMINISTRATOR:HOLLAND, SUSIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 216-8007
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Susie HollandTIME COMPLETED:
11:20 PM
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On August 19, 2022 at approximately 8:10 am, Licensing Program Analyst (LPA) Simerjit Kaur arrived at the facility to conduct UNANNOUNCED RANDOM REQUIRED 1 YEAR SITE INSPECTION. LPA met with licensee Susie Holland. Upon initial arrival there were 7 children. Present during the inspection was licensee's fingerprint cleared assistant Miranda Browning. During the inspection, 5 children arrived. Hours of operation for child care are Monday through Friday, 7:00am to 5:30pm. The facility is a two story house. The following was observed during today’s inspection:

CAPACITY: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were twelve children (one infant, seven preschoolers, 4 school age children) and assistant. The facility is in compliance with ratio and capacity limitations.


ON LIMIT AREAS (accessible to children in care): the converted garage/day care room and the nap/playroom located at the end of hallway (nap/playroom leads through the laundry room) and backyard. The isolation area will be the nap/playroom. The backyard will be a designated outdoor play area that is fully fenced. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There are ample age appropriate toys that are observed to be safe and in good condition. The backyard has a fence surrounding the perimeter of the yard. LPA did not observe any dangerous conditions, nor any hazardous or toxic items accessible to children in the ON Limit areas of the facility today.
OFF LIMIT AREAS (not accessible to children in care): 6 bedrooms, 2 bathrooms, kitchen, family room, and living room. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is advised to contact Licensing Department, so that an inspection can be completed prior to changing an OFF Limit area to ON Limit. There are no pools or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.
Continued on LIC 809C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: HOLLAND, SUSIE
FACILITY NUMBER: 013414402
VISIT DATE: 08/19/2022
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EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 3A10BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. First aid supplies are available. A fire/disaster drill was last conducted on 7/18/2022 and meets the six month requirement. Facility has working telephone service. Per licensee, there are no firearms in the home. LPA reviewed Emergency Disaster Plan which licensee confirmed to still be current.
STAFF/CHILDREN RECORDS REVIEW: Licensee and assistant working in the home have proper criminal background clearances. Licensee has current CPR/First Aid training, which expires on 5/21/24 and assistant's CPR/First Aid training expires on 5/21/24. Licensee’s mandated reporter training was completed on 8/23/21, and assistant completed on 1/12/20. Licensee and staff are in compliance with immunization law. Children's files were reviewed. Licensee maintains an Infant Sleep Plan for infants up to 12 months old, and an infant sleep log for infants up to 24 months. A facility roster is maintained.
LICENSING POSTING (required): All REQUIRED forms are posted and visible for public review: Facility license, Notification of Parents’ Rights, Earthquake Preparedness, Emergency Disaster Plan. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed and that smoking is prohibited in the home during day care hours.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

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.

Continued on LIC 809C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: HOLLAND, SUSIE
FACILITY NUMBER: 013414402
VISIT DATE: 08/19/2022
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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 frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email [email protected] to be included in the Child Care Quarterly Updates distribution list.



To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days. Appeal rights provided.

Exit interview conducted and report was reviewed with the licensee Susie Holland.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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Document Has Been Signed on 08/19/2022 11:12 AM - It Cannot Be Edited


Created By: Simerjit Kaur On 08/19/2022 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: HOLLAND, SUSIE
FACILITY NUMBER: 013414402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the license's assistant Miranda Browning does not have current mandated reporter training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee shall submit copy of completed the mandated reporter training certificate ("child care providers" and "general") to LPA by due date of 9/16/22. WWW.MANDATEDREPORTERCA.COM
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


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