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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416337
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:35:22 PM

Document Has Been Signed on 09/19/2024 02:35 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:PIERCE, FORRESTINEFACILITY NUMBER:
013416337
ADMINISTRATOR/
DIRECTOR:		PIERCE, FORRESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-1109
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
09/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Forrestine Pierce- LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 9/19/24, Licensing Program Analyst Briana Plumboy, met with licensee Forrestine Pierce for an UNANNOUNCED CASE MANAGEMENT ANNUAL CONTINUATION INSPECTION. Present for this visit was 3 infants and 2 preschool age children. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 6:30am until 5:30pm.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The fireplace is screened and also has a barricade to prevent access by children. All REQUIRED forms are posted and visible for public review. The licensees CPR and First Aid certificate is current and expires 2/10/26. The fireplace is screened and also has a barricade to prevent access by children. Per licensee, there are no firearms in the home. The licensee received a certificate in mandated reporter training on 8/6/24. Licensee is in compliance with the immunization law which pertains to providers. The licensee is in ratio today. The licensee documents infant sleep checks and utilizes Lic. 9227. All REQUIRED forms are posted and visible for public review.

Licensee Forrestine Pierce is aware she should have knowledge of all Title 22 Regulations and follow all Title 22 Regulations at all times, as well as follow manufacture guidelines for all equipment in the facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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/.

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.


See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PIERCE, FORRESTINE
FACILITY NUMBER: 013416337
VISIT DATE: 09/19/2024
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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.

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.

LPA discussed the safe sleep regulations with licensee Forrestine Pierce 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 Forrestine Pierce 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.

During the exit interview, the Licensee Forrestine Pierce confirmed that there are no Registered Sex Offenders living in the facility.

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

No deficiencies today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Forrestine Pierce.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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