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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415098
Report Date: 05/17/2021
Date Signed: 05/17/2021 11:44:02 AM

Document Has Been Signed on 05/17/2021 11:44 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:BIRD, BARBARAFACILITY NUMBER:
434415098
ADMINISTRATOR:BIRD, BARBARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 704-1488
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
05/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Barbara BirdTIME COMPLETED:
12:00 PM
NARRATIVE
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On 05/17/2021 at 10am, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Case Management Inspection. LPA met with the Licensee, Barbara Bird and LPA explained the nature of today’s visit. Present on this visit were 1 (one) assistant, Sreevalli Tella and children 8 children, three (3) of them are infants.

The Facility had a Complaint Investigation Visit from Community Care Licensing Investigative Branch (CCL IB) on 04/05/2021. Investigator Megan Muller conducted the investigation and met with the licensee. Investigator observed ten (10) children in care, 5 of them were infants (under the age of 2 years old). The facility was over capacity, maximum allowed infants is four (4) if there are ten (10) children in care.

The attached type A violation is cited today and corrected on the same day. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

An exit interview was conducted with the licensee. The licensee was provided a copy of her/his appeal rights and the signature on this form acknowledges receipt of these rights. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2021
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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Document Has Been Signed on 05/17/2021 11:44 AM - It Cannot Be Edited


Created By: Manel Estoesta On 05/17/2021 at 10:52 AM
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: BIRD, BARBARA
FACILITY NUMBER: 434415098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2021
Section Cited
CCR
102416.5(d)(1)

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102416.5 Staffing Ratio and Capacity (d) (1) Twelve children, no more than four of whom may be infants; or.....

This requirement is not met as evidenced by;
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LPA obtained current roster on this visit, four (4) infants are enrolled, three of them were present on the day of the visit. LPA gave and discussed a pictographic poster regarding staffing ratio and capacity. Licensee understood.
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On 04/05/2021, the facility was over capacity, ten (10 )children were in care, five (5) of them were infants which poses an immediate Health and Safety risk to children in care.
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LPA provided the CCL website to watch and review the FCCH Providers videos.

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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:Jason Jang
LICENSING EVALUATOR NAME:Manel Estoesta
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2021


LIC809 (FAS) - (06/04)
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