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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409128
Report Date: 07/27/2023
Date Signed: 08/04/2023 02:10:19 PM

Document Has Been Signed on 08/04/2023 02:10 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ANDREWS, STACIEFACILITY NUMBER:
073409128
ADMINISTRATOR:ANDREWS, STACIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 783-2643
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Stacie AndrewsTIME COMPLETED:
03:00 PM
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On 07/27/2023 at 12:30PM Licensing Program Analysts (LPAs), A. Curry and S. Blue arrived at the home and conducted an unannounced random inspection. LPA met with licensee, Stacie Andrews, who granted inspection authority to tour the facility. Also present for the inspection were licensee’s assistant, Maria Balcazar and 6 children in care, consisting of 1 infant and 5 preschoolers. Licensee states there are currently 12 children enrolled. Children and staff files were reviewed. Licensee's assistant did not have eligible clearance. Licensee's assistant did have eligible clearance at another licensed facility, but was separated in 2017. The licensee is aware that her assistant should not return to work until she has eligible clearance. Please check Guardian or contact the Oakland office to verify clearance. The licensee was also advised that she must operate as a small if she does not have another eligible assistant.

The children use the downstairs bathroom, living room, family room, kitchen, downstairs bedroom, and backyard. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is the family room away from other children. The LPA toured all areas used by children.



Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There is a screened fireplace made inaccessible to children in care. There were safe toys, play equipment, and materials observed for children. There is a safety gate at the bottom of the stairs. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 3A40BC fire extinguisher, working smoke alarm, and working carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on February 12, 2024 respectively
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ANDREWS, STACIE
FACILITY NUMBER: 073409128
VISIT DATE: 07/27/2023
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AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com The licensee completed the training on February 19, 2023.


LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards .Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was also advised that any infant up to 12 months of age shall have the LIC 9227 form in file. The LIC 9227 form was provided today.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
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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: ANDREWS, STACIE
FACILITY NUMBER: 073409128
VISIT DATE: 07/27/2023
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During the exit interview, the licensee Stacie Andrews, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Stacie Andrews.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2023 02:10 PM - It Cannot Be Edited


Created By: Ashley Curry On 07/27/2023 at 12:57 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ANDREWS, STACIE
FACILITY NUMBER: 073409128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by ensuring all assistants are fingerprint cleared, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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By 08/04/2023 submit livescan receipt. The licensee is aware the assistant is not able to return to work until she has eligible clearance. Please check Guardian or contact Oakland office to verify clearance.
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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


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