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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423286
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:03:49 AM

Document Has Been Signed on 11/17/2021 11:03 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:DALLAS, CALETHAFACILITY NUMBER:
013423286
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:CALETHA DALLASTIME COMPLETED:
11:47 AM
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Licensing Program Analyst Sidney Cortez, met with licensee for an CALETHA DALLAS .UNANNOUNCED ANNUAL RANDOM INSPECTION. Present for this visit was the licensee CALETHA DALLAS. And an Assistant name Camoni Randolphs who is not fingerprint cleared (deficiency was cited) See 809 D. Ms. Randolphs has a livescan form dated 11/15/2021. Ms Randolphs is still not in the Guardian system.


The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:30AM until 6:30 PM, MONDAY-FRIDAY. The home is a two story house which is neat and clean with heating and ventilation for the safety and comfort of the children. The OFF LIMIT AREAS are the garage, the right side area of the backyard, the shed in the backyard and the entire second floor of the home. The off limit areas will be blocked by gate, safety handles and or visual supervision. The ON LIMIT AREAS are the living room, the dinning, the kitchen, the downstairs half bathroom and the backyard. The ISOLATION AREA will be in the living room on the smaller couch. The outdoor play area will be the backyard, which is fenced in and appears to be safe during todays inspection. . There are age appropriate toys that are safe and observed to be clean and in good repair. There are no bodies of water on or near the home. LPA did not observe any hazardous materials or toxins accessible to children today. Per applicant there are no firearms in the home.The outdoor play area will be the backyard, which is fenced in and appears to be safe during todays inspection. . There are age appropriate toys that are safe and observed to be clean and in good repair. There are no bodies of water on or near the home. LPA did not observe any hazardous materials or toxins accessible to children today. Per applicant there are no firearms in the home.There are ample age appropriate toys that are safe and appeared to be clean. There are no pools, hot tubs or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone. The applicant’s Health and Safety training is completed and CPR and First Aid certificates are current and expire SEPT 2023. The applicant is in compliance with new immunization laws which pertain to day care providers. Per applicant, there are no firearms in the home. A copy of the mortgage statement was reviewed and shows control of property.The licensee's mandated reporter training is current and expires (NOVEMBER, 2023).Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on JUNE 23, 2021. 2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809 C for Continuation

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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: DALLAS, CALETHA
FACILITY NUMBER: 013423286
VISIT DATE: 11/17/2021
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LPA Cortez provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee. LPA Cortez provided licensee with a copy of the CDSS handout on Effects of Lead Exposure and Never Shake a Baby Brochure (attached PUB 271)The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.California Law requires Family Child Care Home licensees 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. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.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.govFor licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list. This entire report has been read to the Licensee by LPA Cortez. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Cortez or CCLD. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2021 11:03 AM - It Cannot Be Edited


Created By: Sidney Cortez On 11/17/2021 at 10:41 AM
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: DALLAS, CALETHA
FACILITY NUMBER: 013423286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)


This requirement is not met as evidenced by:
Deficient Practice Statement
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102370(d)
Crimininal Record Clearnce.

Please note: Assistant: Camomi Randolph SSN 608-08-1886 has a live scan form submitted dated at 11/15/21. Checked Guardian still not in the system yet.
POC Due Date: 11/30/2021
Plan of Correction
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Get fingerprint clearance for Camomi Randolph. Advised licensee, assistant cannot be in the facility until background gets 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:Sidney Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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