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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010768
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:44:45 AM

Document Has Been Signed on 10/29/2024 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WILLIAMS, SYMONE FCCHFACILITY NUMBER:
483010768
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, SYMONEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 606-8980
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
10/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Symore WilliamsTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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A prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Glenn Ouye. The applicant is requesting a license for a capacity of 14 children. Services will be available daily 12:00 AM - 11:59 PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a three bedroom, two bathroom, single level home. The 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The applicant provided proof of control of property.

The floor and yard plans are verified. The children will have access to the living room, family room, kitchen, and hallway bathroom. The "off limits" areas include the home's bedrooms, the garage and laundry room. These areas will be made inaccessible by door locks, doorknob slipcovers.. The home appears to be clean and orderly at this time and will remain so during childcare hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. The firearms and ammunition are store separately in a manner that meet Title 22 regulations. Licensee states poisons are locked in a shed in the backyard. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies will be maintained at the facility. 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 rated at least 2A10BC. The home's fireplace and stairs are barricaded. The home's backyard is fully fenced and part of it will be used for childcare. One of the side yards is off-limits and gated, the other is double gated and would be used as an emergency exit. The licensee was told that the side gate must remain latched and closed at all times to maintain the inaccessibility of the body of water across the street.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010768
VISIT DATE: 10/29/2024
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The provider does not have liability insurance, but plans to obtain the liability insurance prior to opening. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented.

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. 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 to: cclrpregionalofficegeneral@dss.ca.gov within seven days. The applicant will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certification. 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. Infants and children shall not be allowed to sleep in car carriers in the home. 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 any area where child care is provided. The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep web page at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. 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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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: WILLIAMS, SYMONE FCCH
FACILITY NUMBER: 483010768
VISIT DATE: 10/29/2024
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On this date, 10/29/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

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 platforms.


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.



Exit interview conducted and report was reviewed with the applicant, Symone Williams.

This is approved for a large FCCH license effective today, October 29, 2024.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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