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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444413332
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:21:54 PM

Document Has Been Signed on 08/13/2021 03:21 PM - 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:AVENELL, LINNAEAFACILITY NUMBER:
444413332
ADMINISTRATOR:AVENELL, LINNAEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 476-0964
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Linnaea AvenellTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Goodell met with licensee, Linnaea Avenell, for the purpose of an Unannounced Annual Random Inspection. Licensee providers after school care. Hours of operation are Monday- Friday, 11:30am- 5:00pm. During inspection LPA, observed 12 children present with licensee and two assistance. All individuals subject to criminal background review have obtained a criminal record clearance.

Inspection was conducted in all areas accessible to children. Off-limits areas include the animal pens (next to detached playroom), the office, three bedrooms located in the house, Master restroom, and the outdoor side deck area. LPA verified current phone number and email are current. LPA also observed a 2A10BC fire extinguisher, smoke and carbon monoxide detectors in both the home and playroom. No weapons, bodies of water or poisons in the home. Licensee acknowledged that 100% supervision is required in unfenced area. LPA observed cleaning compounds, medication and knives are stored inaccessible to children.

Children's records and staff files reviewed. LPA observed proof of immunization records staff not on file. Licensee acknowledged requirement and stated that proof will be submitted to LPA by POC due date. LPA also observed fire drill log and children roster maintained. Preventative health training, current pediatric CPR and first aid certification was verified and expires 8/2023.

Report continues on LIC 809-C
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 08/13/2021 03:21 PM - It Cannot Be Edited


Created By: Kristal Goodell On 08/13/2021 at 02:57 PM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AVENELL, LINNAEA
FACILITY NUMBER: 444413332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
HSC
1597.622(a)(1)

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Employees or volunteers at family day care home; immunization requirements; records; exemptions. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an
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Licensee acknowledged requirement and stated proof will be submitted to LPA via email by 9/10/21.
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influenza vaccination between August 1 and December 1 of each year.

During file staff file review LPA Goodell observed proof of immunizations not available in staff file which poses a potential risk to children in care.
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


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: AVENELL, LINNAEA
FACILITY NUMBER: 444413332
VISIT DATE: 08/13/2021
NARRATIVE
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The Effects of Lead Exposure brochure posted. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, forms, self-assessment guides, legislation and regulation information. PIN 21-08-CCP and COVID-19 UPDATE Guidance: Child Care Programs and Providers were discussed.

Deficiency cited on LIC809-D. LPA reviewed report with the licensee and provided copies. An exist interview was conducted. The Notice of Site Visit issued and must remain posted for 30 days. Appeal Rights also issued and discussed.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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