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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500398
Report Date: 04/30/2021
Date Signed: 05/13/2021 11:24:26 AM

Document Has Been Signed on 05/13/2021 11:24 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN, STEPHANIEFACILITY NUMBER:
344500398
ADMINISTRATOR:GOLDEN, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 200-7570
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
04/30/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stephanie GoldenTIME COMPLETED:
10:30 AM
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*NOTE: Due to Covid-19 State of Emergency and DPH guidelines on social distancing, a facetime meeting was conducted. In lieu of Licensee’s signature, the report is emailed for signatures.*

On 30th April 2021 at 9:00am Licensing Program Analyst (LPA) Aruna Sridharan conducted tele-inspection via Facetime with licensee Stephanie Golden for an announced change of location inspection. Licensee is requesting change of location for a large Family Child Care Home license. Licensee is moving from previously licensed(343622342) address: 825 Ellis Circle, Galt CA 95632 to current home at 1144 Chelsham Ave, Galt, CA 95632. The current address is licensee's own home which was licensed in 2013 with swimming pool(343619055). The hours of operation are Monday-Friday 6:00am to 6:00pm. The fire clearance was received on 04/19/2021. All adults are fingerprint cleared.

LPA toured the single storey, 3 bedrooms and 2 bath home inside and out. OFF LIMIT areas include: master bed/bath, daughter's bedroom, laundry room and garage. Licensee acknowledges that children may never enter these off-limit areas.

The backyard is fenced and there is a swimming pool which has fencing and self latching gate that meets Title 22 swimming pool regulations. The licensee understands that 100% supervision is needed when children are in an unfenced area. Licensee understands that prior to making altercations or additions to the home or grounds the licensee shall notify Licensing Agency per regulation 102416.3

Home has working carbon monoxide and smoke detectors that meet regulations. The 2A-10-B-C fire extinguisher is wall mounted behind the entrance door. There are no firearms as stated by licensee. Fireplace in the living room is blocked by entertainment center. Hazardous cleaning compounds are stored in the locked cabinet under the sink in kitchen and bathroom. Sharp utensils like knives are stored in the kitchen drawer with child safety latch inaccessible to children. The medications are stored in upper cabinet in the kitchen out of reach of children. The home contains appropriate toys for the children.
The Licensee has completed Lead Poisoning Prevention module certificate on 04/13/2021. Licensee has CPR and First Aid (exp:11/2022) and Mandated Reporter (exp: 04/2023).

Licensee is following COVID guidelines and precautions to provide care for children at this time.
Report continues on 809C....
SUPERVISORS NAME: Sharon Ogbodo
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN, STEPHANIE
FACILITY NUMBER: 344500398
VISIT DATE: 04/30/2021
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LPA advised the licensee of their responsibility to stay current in the requirements of the Department by accessing www.ccld.ca.gov for all updated forms, requirements and changes. LPA reviewed the fire drill requirements. LPA reviewed postings. Licensee currently does not have liability insurance and will be using the affidavit for parents to sign.

LPA will recommend approval for a change of location after receiving the following documents-
1) Copy of deed, current mortgage statement or latest property tax statement.
2) Child safety door knobs on bedrooms and laundry room.
3) Pictures of garage- paint cans stored in lock and key, first aid kit in entry closet
4) Corrected 9108-Adult resident
5) Proof of Immunization- Measles instead of Mumps
6) Updated Earthquake Preparedness Checklist.
7) Children's Roster.
SUPERVISORS NAME: Sharon Ogbodo
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC809 (FAS) - (06/04)
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