Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053619656
Report Date: 03/27/2018
Date Signed 03/27/2018 01:17:40 PM

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: 14DATE:
03/27/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Linda RoeTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kiriko Pratt met with Licensee Linda Roe for an annual/random inspection and toured areas of the 3 bedroom/3 bathroom home accessible to children. Off Limits Areas currently include: master bedroom/bathroom, both upstairs bedrooms and upstairs bathroom, sun room, and garage. All adult residents have criminal record clearances. Licensee stated there were no new residents in the home. Staffing ratio and capacity limits were met per regulations. The FCCH Hours of Operation are Monday through Friday 7:00 a.m. to 5:30 p.m.

LPA observed cleaning supplies, medications, knives, and other hazardous items were properly stored in areas made inaccessible to children. Fire extinguisher, smoke detector, and carbon monoxide detector met Title 22 regulations. Licensee maintains landline and cell phone service for the home. Licensee stated there are no weapons in the home. Home was clean and orderly with comfortable accommodations. Stairs are barricaded on the upper and lower levels. Toys, play equipment, and materials were in working condition. Woodstove insert is barricaded by a fence. Backyard is fenced, and there are no bodies of water on the property. Licensee provides 100% supervision in all fenced and unfenced outdoor areas.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Kiriko PrattTELEPHONE: 916-216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2018
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: ROE, LINDA A.
FACILITY NUMBER: 053619656
VISIT DATE: 03/27/2018
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LPA observed the following documents posted: License, Parents Rights Poster, and Emergency Disaster Plan. Licensee also maintains a current facility roster and fire drill log. Children's records were reviewed and included emergency contact information, immunization records, and parents right notifications. Licensee's CPR and First Aid certification is current and CPR expires 09/23/19. LPA informed Licensee of current laws, including changes to immunization regulations and mandated reporter training. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA provided the Licensing Agency website (www.ccld.ca.gov) to the Licensee, so she may obtain updated licensing information, provider information notices (PINs), regulations, and forms. An Exit Interview was conducted. A Notice of Site Visit was provided. No Title 22 deficiencies were cited during today's visit.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Kiriko PrattTELEPHONE: 916-216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2018
LIC809 (FAS) - (06/04)
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