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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500537
Report Date: 12/22/2021
Date Signed: 12/22/2021 11:05:19 AM

Document Has Been Signed on 12/22/2021 11:05 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:WYSOCKI, MICHELLEFACILITY NUMBER:
394500537
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle WysockiTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christopher Jackson met with the applicant Michelle Wysocki for a change of location inspection. LPA conducted a health and safety inspection inside and out of the home. The single story home consist of three bedrooms and two bathrooms. In addition the interior of the home has a family room, living room, kitchen and dining area. The outdoor area has a fully gated in front yard. The backyard is fully fenced. There are three sheds in the backyard area. One shed is located in the boat storage area and two additional sheds are located on the right side of the backyard. LPA observed play equipment in the back play area. Applicant owns the home and provided a copy of the mortgage statement for the home to the department. LPA discussed the option of obtaining $300,000 liability insurance. Applicant understands that until a policy is obtained, applicant must use the affidavit. Off-limit areas are: All bedrooms, backyard sheds, side boat storage area and garage. Applicant understands that children may never enter these off-limit areas. LPA reviewed the fire drill requirements. LPA observed the fireplace is barricaded prohibiting access by children.

Applicant has provided LPA with enrollment dates for the completion of the Lead Training that is required. Applicant stated the will conduct the training on 01/22/22. LPA observed CPR/First Aid certificate expires on 11/23. All adult residents received criminal record clearances. LPA discussed Civil Penalties per person for those adults, including applicants own adult children, who have not received fingerprint clearances. LPA has provided the applicant with the web site to enable access to all updated forms, requirements and changes. The web site is (www.ccld.ca.gov). LPA advised licensee of their responsibility to stay current in regards to new regulations. Applicant understands that they need to notify licensing for any modifications done to the home, inside and outside. LPA observed posted Emergency Disaster Plan and Parents' Rights Poster.


Report Continues on 809-C
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: WYSOCKI, MICHELLE
FACILITY NUMBER: 394500537
VISIT DATE: 12/22/2021
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Fire extinguisher, carbon monoxide detector and smoke detector meet regulation. Hazardous cleaning compounds and medications are stored inaccessible and or out of children reach. Applicant understands that 100% supervision is required in any unfenced areas. LPA observed all firearms and ammunition to be locked and stored according to Title 22 regulations.

Upon completion of the Lead Training, effective today, a provisional license will be granted. To serve a capacity of 6 children with no more than 3 infants or 4 infants only. Or with a capacity of 8 children: no more than 2 infants, 1 child in Transitional kindergarten or elementary school and 1 child at least age 6.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC809 (FAS) - (06/04)
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