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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409353
Report Date: 12/21/2022
Date Signed: 12/21/2022 09:50:14 AM

Document Has Been Signed on 12/21/2022 09:50 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:MOORE, KI-SHAWNAFACILITY NUMBER:
073409353
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:MOORE, KI-SHAWNATIME COMPLETED:
10:15 AM
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On December 21, 2022 at 8:30 AM Licensing Program Analyst (LPA) Nyeesha Blount conducted an announced Pre-Licensing inspection and met with applicant Moore, Ki-Shawna. LPA disclosed the purpose of the inspection and was granted entry into facility by applicant. Present during this inspection was fingerprint cleared Applicant. LPA toured with Applicant for a health and safety inspection. The facility plans to operate Monday – Friday 7:00 AM - 5:00 PM.
The home is a two story which consist of living room, dining room, kitchen, (4) bedrooms, (2) bathrooms, fenced backyard, and garage. The day care is neat and clean and has central heating and ventilation for safety and comfort. There are enough age appropriate furnishings, toys, books and learning materials available. Applicant states there are no weapons in the home. All hazardous materials and toxins were observed to be inaccessible to children today, Knives were stored in an upper cabinet. The day care is equipped with a fully charged 2A10BC fire extinguisher, working smoke detector, and working carbon monoxide detector. Pediatric CPR and First Aid are current and will expire on August 2024.
ON LIMIT: Living room, dining room, downstairs bathroom, back yard.
OFF LIMIT: The entire upstairs.
OUTDOOR SPACE: The entire area was inspected to ensure the health and safety of the area. currently no at this tine there are no play structures. There are no pools, hot tubs, or any bodies of water on the premises during today’s inspection.
ISOLATION AREA: will be the couch in the corner in the living room.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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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: MOORE, KI-SHAWNA
FACILITY NUMBER: 073409353
VISIT DATE: 12/21/2022
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 LPA reviewed the facility staff and children's records including parents' rights forms, emergency ID forms and consent for emergency medical treatment forms. Licensee CPR/First Aid, Mandated Reporter Certificate for Licensee is all up to date.

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. there are no firearms stored or present in the home.

Per incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.htmhttp://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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: MOORE, KI-SHAWNA
FACILITY NUMBER: 073409353
VISIT DATE: 12/21/2022
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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.

Licensee was reminded about importance to stay in compliance with mandated reporter training and maintenance of sleep logs for all infants in care.

Exit interview conducted and report was reviewed with the licensee Moore, Ki-Shawna License Effective December 21, 2022.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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