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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010018
Report Date: 04/01/2021
Date Signed: 04/01/2021 03:52:26 PM

Document Has Been Signed on 04/01/2021 03:52 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,
, CA
FACILITY NAME:DURGIN, DEBRA FCCHFACILITY NUMBER:
493010018
ADMINISTRATOR:DURGIN, DEBRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 753-3052
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 18TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/01/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Debra DurginTIME COMPLETED:
03:45 PM
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An announced tele-visit prelicensing inspection was conducted today by Licensing Program Analyst Jennifer Velasco (LPA). Due to the COVID-19 pandemic, a tele-visit was conducted in place of an in-person site visit. A follow-up in-person site visit may be conducted at a later date. The applicant is requesting a license for a capacity of 8 children. Services will be available Monday through Friday, 07:30 a.m. through 5:30 p.m., year round. During the pre-licensing inspection, LPA provided technical assistance to the applicant related to COVID-19 guidelines and self-assessment. The applicant understands that consecutive, 24-hour care is prohibited. The residence is a two bedroom, two bathroom, two story home. Two adults currently reside in the home. The applicant was advised that all adults residing in or working at the facility must have a criminal background clearance on file with CCLD. The applicant stated they are aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance. The floor and yard plans have been verified. The children will have access to the living room, kitchen, dining nook, one bathroom, one bedroom, side yard, driveway, and garage. The "off limits" areas include one bedroom, one bathroom, the entire second floor, the backyard, and the staircase to the second floor. These areas were made inaccessible by door knob slip covers, locks, and/or child gates. The home appears to be clean and orderly at this time, and the applicant reported it will remain so during child care hours. There is a working telephone in the home. The sharp knives, cleaning supplies, medications, and other potential hazards are stored out of the reach of children in locked cupboards. The applicant stated that there are no firearms or other weapons or ammunition stored on the premises and poisons are kept in a key locked shed in the off-limits backyard. The regulation that poisons are to be locked using a key or combination lock was reviewed.
Continued on LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DURGIN, DEBRA FCCH
FACILITY NUMBER: 493010018
VISIT DATE: 04/01/2021
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Continued from LIC 809.

The applicant states First Aid supplies will be maintained at the facility and kept inaccessible to children and that children in care will have access to age appropriate toys and equipment. LPA observed the home is equipped with a working smoke detector and fire extinguisher rated at least 2-A 10: BC. The applicant stated the home's backyard is fully fenced but it is off limits to children and rendered inaccessible. The applicant stated there is a hot tub rendered inaccessible to children by regulation compliant fencing and that the hot tub is key locked on all four sides and is thus further rendered inaccessible.

Incidental Medical Services (IMS) regulations were reviewed with the applicant. The applicant stated they understand that, if IMS are provided, an updated Plan of Operation shall be submitted and on file with the Department. The applicant states they understand parents must sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Applicant was advised Parent's Rights poster and other required postings must remain posted throughout licensure and that emergency drills must be conducted and documented at least once every six months. Children's records to be maintained were reviewed. Applicant stated they understand 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 stated they will maintain current pediatric CPR and First Aid certification (10/2020), as well as Mandated Reporter Training certification (11/2020). The applicant stated they shall be present in and reside 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 safely by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant stated infants and children shall not be allowed to sleep in car carriers in the home. The applicant stated they clearly understand the maximum number of children for whom care can be provided, 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. Applicant stated they understand smoking is prohibited at all times in any area where child care is provided.



Continued on LIC 812-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DURGIN, DEBRA FCCH
FACILITY NUMBER: 493010018
VISIT DATE: 04/01/2021
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Continued from LIC 812-C.

Applicant stated they understand the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home and that forms and regulations may be obtained from the website: http://ccld.ca.gov/. Megan's Law web site information was provided: http://www.meganslaw.ca.gov. The AAP Guide to Safe Sleep Practices and the Effects of Lead Exposure brochures were provided and reviewed with the applicant. The applicant stated they understand that any authorized employee of the Department may enter and inspect the facility with or without advance notice. The applicant's signature was not obtained during this prelicensing tele-visit, but this report was provided to the applicant, and the read receipt is on file.

This facility meets licensing standards and the application licensure is approved and goes into effect as of 04/02/2021.

The applicant stated they understand that any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
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