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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700412
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:25:43 AM

Document Has Been Signed on 12/07/2022 11:25 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:MINER, KAILANFACILITY NUMBER:
015700412
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Kailan MinerTIME COMPLETED:
11:21 PM
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On Dec 7, 2022, Licensing Program Analyst (LPA) Sidney Cortez conducted an inspection with applicant Kailan Miner, and her fingerprint cleared partner Paul Perilla . The purpose of this inspection was to conduct an Announced Pre Licensing Inspection. Applicants plan to operate the facility Monday through Friday from 7:00 am until 6:00pm. The home was toured to conduct a Health and Safety Inspection. The home is one story. The home consists of 3 bedrooms, 1 bathroom, living room, dining room, kitchen, backyard. The ON LIMIT AREAS are: living room, bathroom, one bedroom being used as a playroom, kitchen, mud room near the dining area, and backyard as play area. The OFF LIMIT AREAS are the 2 bedrooms. The ISOLATION AREA is the living room.
There are toys and learning materials in the play room area. Hazardous materials and toxins are kept out of the reach of children. There is no pool or any type of bodies of water in the home. Per applicant, there is a fire-arm in the house but is locked in a safe, and the ammunition are in a separate safe. The home is neat and clean with heating and ventilation for safety and comfort. The home has one fully charged fire extinguisher (model 2A10BC), and working smoke/carbon monoxide detectors, first aid kit, emergency supplies, and working telephone. The applicant’s Health and Safety training is completed, and licensee’s CPR and First Aid certificates are current and both certificates will expire on Aug 2024. The applicant is in compliance with new immunization law. Applicant received a certificate in mandated reporter training in Sept 2022 which is valid for 2 years.

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.
LPA Cortez provided a copy of Safe Sleep-in child care brochure, a handout "What Does A Safe Sleep Environment Look Like," and a copy of the new California Car Seat Law Changes. The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370). This home is recommended for licensing. This report shall remain on file for 3 years. Exit interview conducted with licensee.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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