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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415987
Report Date: 11/19/2021
Date Signed: 11/22/2021 10:42:49 AM

Document Has Been Signed on 11/22/2021 10:42 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PENNINGTON, KRISTINA & KAITLYNNFACILITY NUMBER:
434415987
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kristina & Kaitlynn TIME COMPLETED:
12:41 PM
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On November 19, 2021 at 9:45AM, Licensing Program Analyst (LPA) Elizabeth Larios conducted an announced pre-licensing visit with applicant Pennington, Kristina. LPA explained the nature of this inspection.The adults that reside in the home are as follows: Applicant, co-applicant Pennington, Kaitlyn and spouse/father Pennington, Dan.The applicants had one child in care.

Physical Plant: LPA Larios & Licensing Program Manager Mary Segura via (FaceTime) toured the indoor and outdoor areas of the home during today's visit to see pending items from prior inspection. LPA observed the following: Off limit areas inside are as follows: One master bedroom/bathroom, one bedroom and one bathroom. The garage. There is a play room area upon entry to the home, to the right that has a gate. LPA observed safety knobs for the following: master bedroom and a separate bath room, the other off limits bedroom is inaccessible by a door code with a knob. LPA observe a safety knob for the door in the laundry room area, which is where children's bathroom will be, that leads to the garage area. LPA observed a barricade for fire place. LPA also observed a deterrent for hall closet. LPA observed one bedroom (#2) that will be used for day care, LPA did not observe any lotions, medications, alcohol and other items that may pose a risk to children in care in bedroom #2. LPA observed a safety device for kitchen drawer that has knives. Off limit areas outside the home are as follows: The entire back yard, due to construction. LPA did observe items that need to be removed and locked. All items were removed and locked. LPA observed right side back yard exit clear. There were no bodies of water observed. Applicant states back yard will be made accessible once construction is complete and will notify licensing. Licensing may return to inspect backyard and update sketch once construction is completed. BB gun is located in garage will remain locked at all times during day care. LPA printed and went over the safe sleep regulations with Applicant.

CONTINUED ON LIC 809-C
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PENNINGTON, KRISTINA & KAITLYNN
FACILITY NUMBER: 434415987
VISIT DATE: 11/19/2021
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An exit interview was conducted with Applicants and Applicants were informed that upon approval of Licensing Management, a license for a Family Child Care Home will be granted and issued to Applicants.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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