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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423662
Report Date: 08/05/2022
Date Signed: 08/05/2022 10:53:22 AM

Document Has Been Signed on 08/05/2022 10:53 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:MILLER, JENNIFERFACILITY NUMBER:
013423662
ADMINISTRATOR:MILLER, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 861-4692
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jennifer MillerTIME COMPLETED:
11:00 AM
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On August 5, 2022 Licensing program Analyst (LPA) Indira Loza arrived at the facility to conduct an annual random inspection. Present for the inspection were the Licensee, Licensee's fingerprint cleared assistant (Hannah Gauthier), and 4 preschoolers. The home was inspected to conduct a Health and Safety check. Operating hours are Monday through Friday 8:30am to 4:30pm.

The home is a single story home consisting of a living room, dining room, kitchen, two bedrooms, two bathrooms, a fenced front area, an outdoor in law suite, and an outdoor toilet and sink. The main child care area is in the backyard, the children enter the home to nap. The off limit areas are the both bedrooms, kitchen (which children only pass through to get to the dining room to nap), the bathroom connected to the bedroom on the left, and the basement. The on limit areas are the backyard, the in law shed, and the dining room in the home, and the bathroom in the hallway between both bedrooms. The Isolation Area is in the nap room.

The Licensee’s Pediatric CPR and First Aid training has been completed and expires February 2023. LPA obtained the children and staff files for review. The Licensee is not providing IMS. The children bring food from home. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children. The Licensee has liability insurance. The home and inlaw shed has a working combined smoke and carbon monoxide detector, as well as a 3A40BC fire extinguisher

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 or fax, Licensee
*****************************************Report Continues on LIC 809-C*******************************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: MILLER, JENNIFER
FACILITY NUMBER: 013423662
VISIT DATE: 08/05/2022
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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. 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 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: 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.
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 athttps://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
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.

There were no deficiencies cited during today's visit. notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Jennifer Miller.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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