Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418810
Report Date: 07/27/2017
Date Signed 07/27/2017 12:34:42 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: 7DATE:
07/27/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kelly StoneTIME COMPLETED:
12:45 PM
NARRATIVE
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LPA's Diana Stephenson and Cherie Acosta met with Licensee Kelly Stone for an UNANNOUNCED RANDOM INSPECTION. Present for this inspection was Licensee, Assistants Nicole O'Brien and Kyra Esmeyer, and 7 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, 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 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 licensee is aware that children are not to be left in parked vehicles.

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 is a firearm in the home and LPA's observed the firearm locked in a big safe located in the master bedroom and the ammunition is located separately is in a small safe located in the garage. 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 7/27/17 indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearance or exemptions.
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Diana StephensonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2017
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: STONE, KELLY
FACILITY NUMBER: 013418810
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2017
Section Cited
H&S 1597.662
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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LICENSEE WILL HAVE 30 DAYS TO PROVIDE APPROPRIATE RECORDS
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OBSERVED LICENSEE DID NOT HAVE IMMUNIZATION RECORDs AVAILABLE DURING THE TIME OF INSPECTION.
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Type B
08/28/2017
Section Cited
102369(b)(9)
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Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
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LICENSEE WILL HAVE 30 DAYS TO PROVIDE APPROPRIATE RECORDS
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OBSERVED LICENSEE DID NOT HAVE TB CLEARANCE RECORDs AVAILABLE FOR THE STAFF DURING THE TIME OF INSPECTION.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Diana StephensonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2017
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: STONE, KELLY
FACILITY NUMBER: 013418810
VISIT DATE: 07/27/2017
NARRATIVE
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Supervision is provided for the children at all times as stated by the licensee. The licensee was informed that if she has to be temporarily away from the home she must arrange for a fingerprint cleared adult with current CPR/First Aid to supervise children. Temporary absences of the licensee shall not exceed 20 percent of the hours that the facility is providing care per day.

When notified by the Department, the licensee shall comply with the removal of any person from the facility, who has specified convictions or for other reasons.

Licensee is aware that any authorized employee of the Department may enter and inspect the home with or without advance notice.

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.

The Type B deficiencies are 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: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Diana StephensonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3