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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525407756
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:48:54 PM

Document Has Been Signed on 08/20/2021 02:48 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:JOHNSON, KRISTINA FAMILY CHILD CARE HOMEFACILITY NUMBER:
525407756
ADMINISTRATOR:JOHNSON, KRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 276-3768
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kristina JohnsonTIME COMPLETED:
12:40 PM
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On 8/20/21 at 11:15 am, an inspection was made to the facility by Licensing Program Analyst (LPA), Wisehart. A review of staff records on 8/20/21 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home.

At 11:25 am the home was toured inside and outside. The licensee and 2 staff were supervising 9 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 6:45 am -5 pm , Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The homes off limits areas include the master bedroom/bath and 2 bedrooms and bathroom which are inaccessible via gates in hallway. Poisons are locked in garage. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. Firearms are locked and the ammunition locked separately. The home is clean, orderly and comfortable. There are safe toys and equipment available for children. There is a working telephone in the home.

There are cribs/play yards available for napping infants. Cribs have firm mattresses and are free of loose objects. Bedding is laundered weekly, and soiled bedding is stored inaccessible to infants. Napping infants are checked on every 15 minutes, and checks are documented on a ledger. No infants were observed to be swaddled, and infants under 12 months are placed on their backs for sleeping.
The children use the side yard as an outdoor play area and it is fully fenced and the stairs accessing the area have a gate at the top/bottom of steps There were no permanent bodies of water on the property and none were observed. The licensee has a wood burning stove which has a secured fire fence around it.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Carrie Wisehart
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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: JOHNSON, KRISTINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407756
VISIT DATE: 08/20/2021
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Four children's records were reviewed at 11:40 am; the required emergency information forms were observed to be on file. Individual Sleeping Plans were not on file for infants (C1/C2)under 12 months of age but the licensee will complete and keep on file. The licensee has completed Mandated Reporter training which expires 7/15/22 . The licensee and all employees have the required immunization's on file except (S1) who needs a TB test. The licensee has current pediatric CPR and First Aid certification, which expire on 6/22.

This report was reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years. The LPA reviewed Safe Sleep, the Lead Flyer and COVID Guidance with licensee.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection though advisories were issued.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Carrie Wisehart
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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