Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053619656
Report Date: 03/02/2016
Date Signed 03/02/2016 11:27:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ROE, LINDA A.FACILITY NUMBER:
053619656
ADMINISTRATOR:MILLER, LINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 754-9011
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY:14CENSUS: 9DATE:
03/02/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Linda RoeTIME COMPLETED:
12:00 PM
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An unannounced annual/random visit is made today by LPA Katina Boulai. Present at time of visit was the licensee and an assistant and 9 day care children.
A tour of the home, inside and outside, as shown on the facility sketch is conducted. Licensee states there are no weapons or firearms in the home. There is no pool at the home and other bodies of water on the premises. LPA observed poisons, cleaning compound's, medications and other hazardous items are inaccessible to children. Fire extinguisher, smoke detector and carbon monoxide detector meet regulations. Stairs are barricaded when children under age 5 years old are present. Safe toys and play equipment are observed. There is a working telephone.
The capacity as specified on the license is being maintained. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Pediatric CPR/FA is current with expiration date of 10/10/2017. A child roster is maintained. Fire and disaster drills are conducted every six months and documented. Some children records reviewed.

Off-limit rooms are: Master Bedroom and guest room. There is a fire place at this facility that is gated according to title 22 regulations. Licensee acknowledges that children may never enter these off-limit areas. During the exit interview, LPA discussed AB 633, Parent Notification Requirements, and the posting of licensing inspection notices and reports. Hours of operation are 7:00-6:00 PM Monday thru Friday and other hours as arranged. Licensee states she does not transport children.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, NO deficiencies are observed today.
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.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Katina BoulaiTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2016
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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