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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417303
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:25:35 PM

Document Has Been Signed on 11/05/2021 05:25 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:KELLY, STACYFACILITY NUMBER:
013417303
ADMINISTRATOR:KELLY, STACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 792-1002
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 13DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Stacy KellyTIME COMPLETED:
05:25 PM
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On 11/5/2021, Licensing Program Analyst (LPA) Jonathan Williams arrived at the facility unannounced for the purposes of a Required 1-Year Inspection. LPA was met by Licensee, Stacy Kelly. Present for this inspection are the Licensee, fingerprint cleared and associated assistant provider, and 13 children in care (four infants, four school aged children, and five preschool-aged children). Facility operating hours are 7am-5:30pm M-F. The facility was toured to conduct a health and safety inspection.

The home is a 1-story home consisting of three bedrooms, kitchen, front room, living room, bathroom, patio room, garage, and backyard. On-limit-areas: entire home except for garage. Off-limit areas: Garage. All off-limit areas are made inaccessible to children via locked and/or closed doors and visual supervision. Isolation room: front room.

At 3:00pm, LPA toured the facility interior. The home is tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the home. There is no fireplace located in the home. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. Furniture accessible to children was observed to be age-appropriate, in operable condition, and free of loose, sharp, or pointed parts. Food/beverages capable of rapid spoiling are properly stored. Uncontaminated drinking water is available to children. There are no firearms kept in the home at this time, per Licensee.



At 3:16pm, LPA toured the outdoor play area. All play equipment was observed to be operable and age-appropriate during this inspection. High climbing equipment has cushioning material to absorb falls. The backyard is fenced. There are no pools, hot tubs, ponds or any other bodies of water located in the on-limit areas of the facility premises at this time.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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: KELLY, STACY
FACILITY NUMBER: 013417303
VISIT DATE: 11/05/2021
NARRATIVE
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The facility has a fully charged 3A40BC fire extinguisher and working telephone. Carbon monoxide detector is functional. Smoke detector is wired to notify the fire department if triggered. Per Licensee, smoke detector is serviced regularly. Mandated Reporter training for Licensee has expired. CPR/1st Aid certificate for Licensee has expired. Licensee produced proof of enrollment in CPR/1st Aid training renewal. The facility is not in ratio today. All required forms are posted in public view. Roster obtained.

Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS to children in care at this time. 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.

Licensee was reminded that California Law requires licensed Family Child Care Homes 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 624b). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the Licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The 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.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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: KELLY, STACY
FACILITY NUMBER: 013417303
VISIT DATE: 11/05/2021
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 as 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.

Deficiencies were cited today, including one Type A deficiency. LIC9224 must be delivered to parents of children in care, including parents of all newly enrolled children for a period of 12 months from the date of today's visit, and signatures must be obtained. A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided to the Licensee and the signature on this form acknowledges receipt of these rights. Exit interview was conducted and report was reviewed with the Licensee.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 05:25 PM - It Cannot Be Edited


Created By: Jonathan Williams On 11/05/2021 at 04:39 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: KELLY, STACY
FACILITY NUMBER: 013417303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA observation, the licensee did not comply with the section cited above. This poses an immediate health, safety or personal rights risk to persons in care. LPA observed during today's visit that 13 children were in care, including 4 infants.
POC Due Date: 11/05/2021
Plan of Correction
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During visit, parent picked up child, placing facility into ratio. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 05:25 PM - It Cannot Be Edited


Created By: Jonathan Williams On 11/05/2021 at 04:39 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: KELLY, STACY
FACILITY NUMBER: 013417303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above which posed potential health, safety or personal rights risk to persons in care. LPA observed an infant under the age of 12 months in a crib that had a stuffed toy inside. Per Licensee, the infant had been sleeping with the toy in the crib. Licensee immediatly removed the toy from the crib.
POC Due Date: 11/05/2021
Plan of Correction
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Cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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