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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423669
Report Date: 10/08/2021
Date Signed: 10/08/2021 11:12:42 AM

Document Has Been Signed on 10/08/2021 11:12 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:COOPER, ELIZABETHFACILITY NUMBER:
013423669
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Elizabeth CooperTIME COMPLETED:
12:30 PM
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On 10/08/2021, Licensing Program Analyst (LPA) Brittany Newton conducted an announced visit for the purpose of conducting a change of location, prelicensing visit. LPA was met by applicant Elizabeth Cooper. Present for the inspection was 0 children. LPA toured the home with the applicant.
The home is a 2 story home with 3 bedrooms, 2 bathrooms, and a small outdoor play area. Operating hours will be Monday through Friday 8:00am to 5:30pm. The applicant plans to provide breakfast, lunch, and a snack.
The off limit areas are the entire upstairs, the kitchen, and bedroom 1 downstairs. On limit areas are the living room, dining room, downstairs bathroom, downstairs bedroom 2, and the outdoor play area. The main day care area is the living room. The applicant set up bedroom 2 for changing and an additional nap area.
LPA inspected bathroom for children. Locks were observed on cabinets to ensure inaccessibility. Paper towels are available. There is a heater in the living room that is screened to prevent access of children.
A gate blocks the stairs leading upstairs as well as the entry to the kitchen. There is a working carbon monoxide and smoke detector on site. There is a 2A10BC fire extinguisher located near the back of house. LPA let applicant know there needs to be one accessible in home.
Outdoor play area was inspected. The outdoor play area is next to the leasing office of a apartment building. Applicant has a safety gate around a padded area for children.
There are ample age appropriate toys that are safe and appear to be clean and in good repair. There are no pools, hot tubs or any other bodies of water. LPA did not observe any hazardous materials or toxins accessible to children today.
CPR and First Aid is current for the applicant expiring November of 2021.
Per applicant, there are no firearms in the home.
Incidental Medical Services (IMS) policy was discussed. 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.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Newton
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: COOPER, ELIZABETH
FACILITY NUMBER: 013423669
VISIT DATE: 10/08/2021
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The applicant was 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. The applicant was reminded of the responsibility as a mandated reporter.


APPROVAL OF LICENSE.
The applicant is now approved to operate as a small family day care home. Facility license will be mailed.

A Notice of Site visit was given and licensee was reminded that it is required to be posted for 30 days.

Exit interview conducted and appeal rights provided, and a copy of this report was left with Elizabeth Cooper.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Newton
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
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