Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313619903
Report Date: 05/18/2016
Date Signed 05/18/2016 01:26:53 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:GRIFFIN, JENNIFERFACILITY NUMBER:
313619903
ADMINISTRATOR:GRIFFIN, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 899-1887
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:14CENSUS: 6DATE:
05/18/2016
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jennifer GriffinTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Amie Randa met with licensee Jennifer Griffin for an unannounced annual inspection. The facility operations Monday-Thursday from 7:00am-5:00pm. LPA toured all areas of the home that are accessible to the children and observed care and supervision, a current roster of children, capacity and ratio. Today’s census was six children, two under the age of two years old, Also present in the home was the licensee's assistant who has been fingerprint cleared. LPA confirmed that all adult residents residing or working in the home have criminal record clearances. LPA advised licensee if anyone over the age of 18 years old moves into the home they must have a criminal record clearance as well. LPA observed posting of the license, Parent's Rights and the current disaster plan.

Off-limit areas include deck and master bedroom/bathroom
Licensee acknowledged that children may never enter these off-limit areas. The backyard is fenced and licensee acknowledges that children may never be left unsupervised in an unfenced area of the yard. LPA observed that the licensee had stairs barricaded. There are no bodies of water on the property and licensee stated there are no weapons in the home.

LPA observed current CPR and First Aid certificates that expires on 01/2018. LPA observed that poisons are locked and that fire extinguisher, smoke detector and carbon monoxide detector meets regulation. Wood burning stove is not in use, cleaning materials, hazardous items and medications are all inaccessible to children. There is a working telephone, toys appear to be in a safe condition and the home appears to be clean and orderly.

LPA provided the Community Care Licensing’s website (www.ccld.ca.gov), so the licensee can obtain updated licensing information, new regulations and access forms.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2016
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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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: GRIFFIN, JENNIFER
FACILITY NUMBER: 313619903
VISIT DATE: 05/18/2016
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LPA discussed the new Immunization Regulations (SB 277- Public health: Vaccinations), new smoking regulation (AB 1819-Smoking Prohibition) and the new Incidental Medical Services (IMS) policies with the licensee.

The facility is not providing IMS at this time. LPA discussed IMS service requirement to create a Plan for Providing IMS. Specifics on the plan can be found in FCCH EM Policy 102417.

No Title 22 Deficiencies cited were observed in the areas that were evaluated. Exit interview conducted, Appeal Rights provided and Notice of Site Visit posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2016
LIC809 (FAS) - (06/04)
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