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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010299
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:56:30 PM

Document Has Been Signed on 10/26/2022 03:56 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HINES, DELLEISHA FCCHFACILITY NUMBER:
483010299
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dellesiha Hines - ApplicantTIME COMPLETED:
04:10 PM
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A Pre-licensing inspection visit was conducted today by Licensing Program Analyst (LPA), Melchisedeck Augustin. The applicant is requesting a license for a capacity 8. Services will be provided Monday - Saturday; 5:00 am. - 7:00 pm. The applicant understands that childcare must be provided in the "primary" residence of the applicant. The residence is a three bedroom/one bath home. There is one adult and four minors living in the home. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The floor and yard plans are verified. The three bedrooms, kitchen and garage are off limits to the children. These areas have been made inaccessible by means of locking mechanisms and children’s safety gates. The on-limit areas consist of the living and dining area, one bathroom, and backyard. The facility did not have any staircases, however; the wooden deck in the yard had two steps. The home appears to be 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 wall electrical outlets had child proof safety covers. The dining area was designated as the Isolation Area. The applicant stated she did not store any firearm(s) or other dangerous weapon(s) on premise, and none was/were observed by the LPA. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector and carbon monoxide detector, and fully charged fire extinguisher rated at least 2A10BC. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HINES, DELLEISHA FCCH
FACILITY NUMBER: 483010299
VISIT DATE: 10/26/2022
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The wall heater was securely screened. The water faucet in the on limits bathroom was warm to the touch in 25.7 seconds. There was/were no trampoline and/or baby walker(s) on premise.

There is no pool, spa, pond, fountain, nor any other source of water accessible to the children, and none is to be added without prior notification and approval of the licensing agency.

Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional childcare liability insurance. Proof of control of property or landlord notification/consent and AB 1207 Mandated Reporter Training certificate are on file. Parent's rights are 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. 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 during the hours of operation in those areas where children are present.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for providing IMS must be submitted to the Department. 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. This report, as well as the AAP Guide to Safe Sleep Practices brochure were reviewed and discussed with the applicant.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HINES, DELLEISHA FCCH
FACILITY NUMBER: 483010299
VISIT DATE: 10/26/2022
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LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA reviewed COVID-19 Child Care Program Self-Assessment Guide with the applicant.

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 applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.

Exit interview conducted and report was reviewed with the applicant, Delleisha Hines. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department. The facility is ready for a Small Family Child Care (FCCH) license effective, 10/27/22.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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