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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455407903
Report Date: 05/03/2021
Date Signed: 05/03/2021 01:05:52 PM

Document Has Been Signed on 05/03/2021 01:05 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:LACKEY, CHEYENNE FAMILY CHILD CARE HOMEFACILITY NUMBER:
455407903
ADMINISTRATOR:LACKEY, CHEYENNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 768-6397
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Cheyenne LackeyTIME COMPLETED:
10:25 AM
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The facility pre-licensing inspection was conducted via tele-inspection due to the current state of emergency regarding the COVID-19 outbreak by Licensing Program Analyst, Wisehart. The applicant is requesting a license for a capacity of 14. The Fire Clearance was approved on 4/21/21, by the Local Fire Authority.

Services will be available Monday - Friday 7:00 am - 6:00 pm. The residence is a 2-bedroom, 2 bathroom home. There is one adult living in the home. The applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.


Children will have access to the living room; dining room; master bed room/baby room and both bathrooms. The homes off limits areas include kitchen and garage. These areas were made inaccessible via gates and door knob covers. The poisons/chemicals are stored in the locked backyard shed, which LPA confirmed during the tour. The applicant understands that poisons shall be kept locked. The home appears clean and orderly at this time and will remain so during childcare hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children. The applicant stated there are no firearms and ammunition stored on this site, which LPA confirmed during the tour. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector and a fire extinguisher which is rated at least the 2A10BC . The applicant stated children will use the front and back yard as an outdoor play area and they are fully fenced. The facility has a wood burning stove which has a secured fire fence. There were no permanent bodies of water on the property and none were observed.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Carrie Wisehart
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2021
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: LACKEY, CHEYENNE FAMILY CHILD CARE HOME
FACILITY NUMBER: 455407903
VISIT DATE: 05/03/2021
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Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (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.htm.
Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional childcare liability insurance. Control of Property is on file. Parent's rights poster will be posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The roster is to remain current at all times. Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current on Pediatric CPR and First Aid (expires 10/21) as well as Mandated Reporter Training (expires 3/28/21). The applicant shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current Pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in those areas where childcare is provided. The Licensee understands that the use of baby walkers, bouncers, inclined sleepers or similar items are not approved equipment for use in licensed childcare homes.
The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family childcare home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/. Megan's Law web site was provided (http://www.meganslaw.ca.gov). The licensee understands that any authorized employee of the Department may enter and inspect the facility with or without advanced notice. This report was reviewed and discussed with the applicant. Guide to Safe Sleeping Practices pamphlet and the Lead Exposure Testing flyer were discussed with the applicant.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Carrie Wisehart
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
LIC809 (FAS) - (06/04)
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