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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415183
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:24:23 PM

Document Has Been Signed on 07/12/2022 12:24 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:CLARK, FREDAFACILITY NUMBER:
013415183
ADMINISTRATOR:CLARK, FREDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 427-1775
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 0DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Freda ClarkTIME COMPLETED:
12:19 PM
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On 7/12/2022 at 10:34am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Freda Clark for an Unannounced Annual Inspection. Present during the inspection was the Licensee. No children were present during the inspection. Licensee lives in the home with her adult daughter. The facility operates 24hours.

ON LIMITS AREA: Family Room and Downstairs Bathroom and Backyard
OFF LIMITS AREA: 2nd Floor, Living Room, Dining Room, Kitchen, all Bedrooms
ISOLATION AREA: Family Room

The facility is a two-story home owned by the Licensee. The inside and outside of the home was observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms and no pets in the home.

The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen. There is one (1) working smoke /carbon monoxide detector in the living room. The fireplace in the dining room is covered and made inaccessible to the children. The home is equipped with two (2) wall heaters. The wall heater in the living room is non operational and the wall heater in the hallway is in use and screened making it inaccessible to the children in care. The stairs are blocked with a gate making the second floor inaccessible to the children. LPA did not observe any harmful bodies of water in or around the home.


Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: CLARK, FREDA
FACILITY NUMBER: 013415183
VISIT DATE: 07/12/2022
NARRATIVE
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The Licensee Health and Safety training has been completed. Licensee Pediatric CPR and First Aid training is expired and needs to be renewed. Licensees Mandated Reporter training is also expired and will be renewed. Fire/disaster drill has been complete with the last drill logged 5/1/2022. All adults in the home have obtained a criminal record clearance. LPA obtained the children’s files, and facility roster. All files are complete.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

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.

Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: CLARK, FREDA
FACILITY NUMBER: 013415183
VISIT DATE: 07/12/2022
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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.

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.

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


Exit interview conducted and report was reviewed with Licensee Freda Clark.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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