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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700419
Report Date: 01/23/2023
Date Signed: 01/23/2023 09:24:38 AM

Document Has Been Signed on 01/23/2023 09:24 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:DORN, DAVIDAFACILITY NUMBER:
015700419
ADMINISTRATOR:DORN, DAVIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 247-5241
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
01/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Davida DornTIME COMPLETED:
09:30 AM
NARRATIVE
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On January 23, 2023, at 8:00 AM., Licensing Program Analyst (LPA) Elimika Woods conducted an announced Announced Prelicensing Inspection for the purpose of a Change in Location and Change of Capacity and met with licensee, Davida Dorn. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection were two children, one infant and one preschool age child. The facility was toured to conduct a health and safety inspection. The facility plans to operate between the hours of 7:30 AM-6:00 PM, Monday -Friday

This two story townhouse, which is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS WHERE CHILDREN WILL NOT BE PERMITTED: the entire second level of the home which will be inaccessible by a barrier gate at the bottom of the staircase and the kitchen area which would be used as a walk through to get to the bathroom. The Isolation area will be a section of the living room, away from other children in care.

There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection.

On-limit-areas are the: Living and dining room, and down stairs bathroom

Off-limit-areas are : Entire second floor, kitchen, and backyard

See 809-Continuation
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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: DORN, DAVIDA
FACILITY NUMBER: 015700419
VISIT DATE: 01/23/2023
NARRATIVE
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For outdoor activities, the licensee states that she would take the children to the local park and the licensee is reminded to have 100% supervision at all times while away from the facility.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, pull down fire alarm, and telephone. Per licensee, there are no firearms in the home. All required forms are posted and visible for public review.

A copy of the rental agreement was reviewed and shows control of property. The licensee completed and received a certificate in mandated reporter training on 04/13/2022. Licensee's CPR and First Aid certificate is current and expires 8/2023.



Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 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 is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

Roster of the children must be properly maintained and fire/disaster drill every six months must be documented. The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

See 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
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: DORN, DAVIDA
FACILITY NUMBER: 015700419
VISIT DATE: 01/23/2023
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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.

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.

This home has been approved for capacity change by the Alameda County Fire Department on 01/09/2023.

This home is recommended for Licensure on 01/23/2023. This report shall remain on file for 3 years. Exit interview conducted with licensee, Davida Dorn.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC809 (FAS) - (06/04)
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