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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010202
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:26:19 PM

Document Has Been Signed on 09/11/2024 04:26 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:JONES, KELSIE FCCHFACILITY NUMBER:
493010202
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
09/11/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:16 PM
MET WITH:Kelsie JonesTIME VISIT/
INSPECTION COMPLETED:
04:27 PM
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A change of capacity inspection- case management inspection was made today by Licensing Program Analyst (LPA) Y. Yang. The licensee is requesting a license for a capacity of 14 children. Landlord consent is on file. The fire clearance for the requested capacity was received by the Department on 09/11/24. Services will be available Tue- Fri 06:30 AM - 05:00 PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a three bedroom/ two bathroom, single level home. There are two adults living in the home. The licensee was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The licensee is 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 are verified. The children will have access to all areas of the home except for the master bedroom and bathroom, which are off limits to daycare children. This area is made inaccessible by door locks, latches, door knob covers, and/or child gates. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home (licensee's cell phone). The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. Licensee stated that there are no poisons stored in the home. Licensee confirmed that firearms and ammunition are stored according to regulations. 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 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 2-A 10:BC. The home's backyard is fully fenced and used for childcare. There is no spa, pool, pond, or fountain observed on the premises and none shall be added without prior approval of the Licensing agency.

The increase of capacity application for a capacity of 14 has been approved effective today's date. The exit interview has been conducted and this report has been reviewed with the licensee, Kelsie Jones. Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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