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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414402
Report Date: 08/25/2023
Date Signed: 08/28/2023 01:12:14 PM

Document Has Been Signed on 08/28/2023 01:12 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
OAKLAND SOUTH EAST, 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: 7DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Susie HollandTIME COMPLETED:
11:00 AM
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On August 25, 2023, 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 5 children. Present during the inspection was licensee's fingerprint cleared assistant Miranda Browning. During the inspection, 2 children arrived. Hours of operation for child care are Monday through Friday, 7:00am to 5:00pm. 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 seven children (three infants, four preschoolers) and an 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 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.
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 today.
Continued on LIC 809C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HOLLAND, SUSIE
FACILITY NUMBER: 013414402
VISIT DATE: 08/25/2023
NARRATIVE
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EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 3A40BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. A fire/disaster drill was last conducted on 8/17/23 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 and assistant has current CPR/First Aid training, which expires on 5/21/24. Licensee’s mandated reporter training was completed on 8/14/23, and assistant completed on 8/24/22. 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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 Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Continued on LIC 809C

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

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HOLLAND, SUSIE
FACILITY NUMBER: 013414402
VISIT DATE: 08/25/2023
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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 informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
During the exit interview, Licensee Susie Holland, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
A notice of site visit was given and must remain posted for 30 days. Exit interview conducted Susie Holland. Appeal Rights provided.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2023 01:12 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 08/25/2023 at 10:23 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: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, the play structure stairs bottom wood panel is loose, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee shall complete the fixtures and send proof to LPA by 9/1/23.
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: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


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