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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416419
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:11:34 PM

Document Has Been Signed on 08/16/2021 02:11 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:COLLVER, LISAFACILITY NUMBER:
013416419
ADMINISTRATOR:COLLVER, LISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 552-7187
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Lisa CollverTIME COMPLETED:
02:30 PM
NARRATIVE
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On August 16, 2021 at approximately 10:32am Licensing Program Analyst (LPA) Haderer arrived for an unannounced 1-Year Required annual inspection. Present in the home today was licensee Lisa Collver, her fingerprint cleared helper Sahanaashok Gudi, and daughter Phoebe Collver-Freeland 14 children in care (1 infant; 3 two-years; 3 three-years; 1 four-years; 5 five-years; 1 six-years). The facility is in ratio today. The home was toured to conduct a health and safety inspection. The home is neat and clean with heating and ventilation for safety and comfort. Hours of operation for day care are Monday through Friday, 8:00am to 6:00pm.

The home is a single-story ranch stye house with 3 bedrooms, 2 1/2 bathrooms, kitchen, (plus a nook); a “great room” (former dining room with a fireplace now a play area), a living room (play area), a children’s ½ bath and a 2-car garage. There is a large backyard play area divided up into 5 sections with farm animals and play structures. There are 3 pigs, 2 goats, 2 chickens in pens (one goat has grown horns and as a result the pen is off limits to children). The perimeter of the property is surrounded by a fence. Licensee also has a dog and 2 cats, who LPA were told have current vaccinations. There are ample age appropriate toys.

Toxins, medicines, and hazardous items were inaccessible. Facility has a waiver for a woodburning stove.

ON LIMIT AREAS include the Kitchen, dining room and living room (play/activity rooms), 1/2 bathroom near front door, backyard frontyard.

OFF LIMITS: The remainder of home. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The outdoor play area and child playhouses were found to be free from defects or dangerous conditions.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: COLLVER, LISA
FACILITY NUMBER: 013416419
VISIT DATE: 08/16/2021
NARRATIVE
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There are ample age appropriate toys in good condition and activities available for children. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection.

The home has a fully charged 2A10BC fire extinguisher; appropriate smoke detectors and carbon monoxide detectors (tested and working). There is a woodburning fireplace in the great room (day care area) with a waiver and a screen to prevent access to children. Liability insurance supplied by ACC and is current through 1/07/2022

The licensee’s Health and Safety training is completed, and CPR and First Aid certificate is current and expires 01/09/2023. Mandated Reporter is current and expires 08/09/2022. Assistant’s CPR and First Aid certificate is current and expires 7-29-2023. Mandated Reporter is also current and expires 5/31/22. Licensee is in compliance with immunization laws pertaining to family day care homes. Licensee’s daughter and a staff member do not have proof of TB tests.

Licensee was reminded that CPR/1st Aide and Mandated Reporter training is to be renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. Per licensee, there are no firearms in the home.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov .http://www.myccl.gov/

At 11:50am, facility and children’s files were reviewed. Some of the files were missing LIC9150 – PARENT NOTIFICATION ADDITIONAL CHILDREN IN CARE. One file was missing a parent’s signature on LIC 627B CONSENT FOR EMERGENCY MEDICAL TREATMENT. As stated above, a staff member and licensee's daughter do not have proof of TB tests.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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: COLLVER, LISA
FACILITY NUMBER: 013416419
VISIT DATE: 08/16/2021
NARRATIVE
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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.

LPA discussed new Safe Sleep requirements for infants up to 12 months.



There were deficiencies cited today. Refer to LIC 809-D for details.

The report will remain on file for three years. A notice of site visit was provided, and the licensee was reminded to have it posted for 30 days.

An exit interview was conducted, LPA left facility at 2:30pm.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/16/2021 02:11 PM - It Cannot Be Edited


Created By: Russell Haderer On 08/16/2021 at 01:36 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: COLLVER, LISA
FACILITY NUMBER: 013416419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2021
Section Cited
CCR
102417(g)(7)

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102417 Operation of a Family Child Care Home

(g)(7) .... the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licenee will contact the child's parent and have the parent sign the LIC627B Consent for Medical Treatment form. This must be done by 8/17/2021
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This requirement is not met as evidenced by:

Based on observation and interview, the licensee did not maintain a signed LIC 627B Consent for Medial Treatment in a child's file, which poses a health and safety risk to children in care.
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Type B
08/16/2021
Section Cited
CCR102421(d)

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102421 Child's Records

(d) In any case in which the licensee cares for an additional child pursuant to Section ...102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child's record, proof of parent notification that the facility is caring for an additional child....
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Licenee will contact the children's parents and have the parents sign the LIC9150 Parent Notification Additional Children in Care. This must be done by 8/21/2021.
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This requirement is not met as evidenced by:

Based on observation and interview, the licensee did not maintain a signed LIC 9150 Parent Notification Additional CHildren in Care in a child's file, which poses a health and safety risk to children in care.
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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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2021 02:11 PM - It Cannot Be Edited


Created By: Russell Haderer On 08/16/2021 at 01:46 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: COLLVER, LISA
FACILITY NUMBER: 013416419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2021
Section Cited
CCR
102369(b)(9)

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102369 Application for Initial License

(b) (9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
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Licensee to ensure all adults living in the home and staff helpers and assistents possess tests for Tuburculosis. Licensee will ensure these tests are complete within 5 business days.
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This requirement is not met as evidenced by:

Based on observation and interview, the licensee did not maintain a signed records of TB tests for a family member and a staff member, which poses a health and safety risk to children in care.
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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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


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