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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623263
Report Date: 09/28/2023
Date Signed: 09/28/2023 09:52:08 AM

Document Has Been Signed on 09/28/2023 09:52 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HAYWARD, TERRIEFACILITY NUMBER:
343623263
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Terrie HaywardTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Michelle Perez met with Licensee, Terrie Hayward, for the purpose of an unannounced required 1-year inspection. The licensee's husband, daughter and child were present during today's inspection. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed a total census of 2 preschool child and one infant supervised by licensee.

Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include all upstairs. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. Toxic and hazardous items are inaccessible to children. There is no fireplace in the home. Stairs were barricaded to prevent access when children under 5 are present. Outdoor play space is fenced.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HAYWARD, TERRIE
FACILITY NUMBER: 343623263
VISIT DATE: 09/28/2023
NARRATIVE
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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. LPA reviewed children’s files. A current roster is being maintained and fire and disaster drills are documented. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires 1/8/2024 and AB 1207 Mandated Reporter Training expires in November 2024.

LPA observed two play yards at the facility. Play yards were free of loose objects. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

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
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HAYWARD, TERRIE
FACILITY NUMBER: 343623263
VISIT DATE: 09/28/2023
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s personnel, and administrative records. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 513-0301 (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.ht

No Title 22 deficiencies were cited during today's visit.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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