Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418810
Report Date: 06/17/2016
Date Signed 06/17/2016 01:51:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:STONE, KELLYFACILITY NUMBER:
013418810
ADMINISTRATOR:STONE, KELLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 803-1565
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 13DATE:
06/17/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kelly StoneTIME COMPLETED:
02:00 PM
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3) Licensing Program Analyst Diana Stephenson met with Licensee Kelly Stone for an UNANNOUNCED RANDOM VISIT. Present for this visit was Licensee, Adult son Jared Childers, Assistant Nicole O'Brien and 13 children in care. The home was toured to conduct a Health and Safety Inspection. There was a current facility roster available for review. The home is one story which consists of 3 bedrooms, master bathroom, main bathroom, family/nap room, dining area, kitchen, day care room, garage, and fenced backyard. The home has centralized heating and ventilation for safety and comfort. The OFF LIMIT AREAS are all the bedrooms/master bathroom and garage which will be inaccessible by closed and/or locked doors and visual supervision at all times. The ISOLATION AREA will be the family/nap room. The fenced outdoor play area is free from defects or dangerous conditions. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. The home has a fully charged 2A10BC fire extinguisher, working smoke detector and carbon monoxide detector, working telephone, and first aid kit. The licensee CPR and First Aid certificate is current and expires 5/28/18. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills at least once every six months. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed and that smoking is prohibited in the home during day care hours. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. A review of staff records on 6/17/16 indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearance or exemptions. Licensee was reminded that anyone working, residing or frequently visiting the home must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Also discussed: nutrition education; the new appeal process; and documents to be provided to parents/legal guardians. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates. This facility is not providing Incidental Medical Services-IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417. There were no deficiencies cited today. Notice of site visit was posted by Licensee at the time of the inspection, and must remain posted for 30 days. Exit interview conducted. Licensee was provided a copy of their appeal rights.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana StephensonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2016
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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