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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415672
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:02:48 PM

Document Has Been Signed on 05/13/2022 03:02 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:FUHRMAN, KIMBERLYFACILITY NUMBER:
013415672
ADMINISTRATOR:FUHRMAN, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 304-9238
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kimberly FuhrmanTIME COMPLETED:
03:15 PM
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On 05/13/2022 approximately at 12:05PM Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Kimberly Fuhrman. Present for this inspection was one infant and four preschoolers. Also residing in the home is the licensee's fingerprinted husband and her fingerprinted adult daughter. Licensee also has a fingerprinted adult son, however he does not reside in the home. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 5:00am to 5:00pm.

ON LIMITS: left side bedroom #1, bathroom #1, fenced backyard, right side yard, kitchen, and bedroom #2
OFF LIMITS: master bedroom, master bathroom, garage, dining room, left side yard . Off limit areas are inaccessible by closed and/or locked doors, and visual supervision.

The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. There were ample age appropriate toys that were observed to be safe and in good condition. At 12:15PM, LPA toured the ON limit areas; LPA observed there was a floor cleaner inside the kitchen area as there were no child safety locks on the drawers. At 12:21PM LPA also observed a pack of disposable razors in one of the cabinets. Type B deficiency was cited, See LIC 809D. LPA also toured the backyard that has age appropriate play equipment, which has plenty of shade; LPA informs licensee that the right side yard area would need to have visual supervision as it may hinder the licensee's ability to see all the children. At 1:49PM, LPA also observed a blue baby bouncer in one of the bedrooms used for sleeping; LPA verified with licensee and was not aware that it was not allowed. Licensee states she would remove it today. There were a 2A10BC fire extinguisher, working carbon monoxide, smoke detectors, and telephone. The home has a fireplace but is blocked off and has a wood burning stove waiver posted. Per licensee, there are no firearms or pets or any bodies of water in the home. The licensee conducts and documents fire drill log indicates a drill was conducted 01/03/22.
SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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: FUHRMAN, KIMBERLY
FACILITY NUMBER: 013415672
VISIT DATE: 05/13/2022
NARRATIVE
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Required documents such as license, wood burning stove waiver, and LIC 610A (Emergency Disaster form) were posted. LPA verified with licensee that PUB 394 (Notification of Parent's Rights Poster) is not available. LPA will send a copy to licensee via email per licensee's request.

At 1:00pm, 5 children's files were reviewed and found to be missing a child's file; per licensee she has another child who is enrolled however she does not have a physical file for LPA to review; LPA suggests licensee to send copies of required documents by 6/3/2022. Licensee was able to provide proof of family liability insurance through All States for her facility until 09/2022; LIC 282 is not needed. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. Licensee has proof of the required immunization. The licensee have required mandated reporter training that is completed as of 08/01/2021. CPR and First Aid training are also updated as of 08/22/2022.

There were TWO deficiencies were cited for today's inspection:
At 12:21PM LPA also observed a pack of disposable razors in one of the cabinets. Type B deficiency was cited, See LIC 809D.
At 1:00PM, LPA verified and made aware that 1 child's file is not available to review. Type B deficiency was cited see LIC 809D

Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Kimberly Fuhrman

SEE LIC 809 C





SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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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: FUHRMAN, KIMBERLY
FACILITY NUMBER: 013415672
VISIT DATE: 05/13/2022
NARRATIVE
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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 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.

Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care. 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.


SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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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: FUHRMAN, KIMBERLY
FACILITY NUMBER: 013415672
VISIT DATE: 05/13/2022
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Licensee was reminded that California Law requires licensed Child Care Centers 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 electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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 inspectionprocess@dss.ca.gov. 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.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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Document Has Been Signed on 05/13/2022 03:02 PM - It Cannot Be Edited


Created By: Kelly Phan On 05/13/2022 at 02:31 PM
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: FUHRMAN, KIMBERLY
FACILITY NUMBER: 013415672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 as LPA observed some disposable razors in an ON limit area (bathroom drawers), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Licensee was able to remove disposable razors today, 05/13/2022 seen by LPA
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as 1 child's file out 6 children files that did not have any required forms at all including immunizations, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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LIcensee would request immunization and signed documents from child's parents
Licensee would send proof of corrections to LPA by 06/03/2022
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:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


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