Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 12/16/2015
Date Signed 12/16/2015 03:48:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:BORNEMAN FAMILY CHILD CAREFACILITY NUMBER:
426205523
ADMINISTRATOR:TRACEY ANN BORNEMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 937-1680
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 10DATE:
12/16/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Tracey Ann BornemanTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(3) Licensing Program Analyst (LPA) Maria Mueller conducted an annual random visit and met with licensee, Tracey Ann Borneman. LPA observed 10 children in the home. Licensee is in the home with 2 assistants. The living room, dining area, and side playroom are used for day care. The home is clean and free of toxins. The cleaning supplies are stored in the garage locked / secured. The knives are stored in a higher cabinet, inaccessible to children. The fireplace is properly screened and inaccessible to children. Licensee provides age appropriate toys, books, videos, equipment and napping equipment.
The bathroom is clean and free of toxins. The bedrooms are off limits to children. Licensee placed a gate in the hall way. Licensee stated that one bedroom is used for napping only.
The outdoor play area is completely fenced, LPA observed bike area, shade area, play structure with cushioning, sand box, small play house, bikes and grass area. There are no bodies of water observed.
The fire extinguisher was serviced May 15, 2015. The smoke alarm was tested and was found operational. The home has a functioning carbon monoxide. The safety drills were conducted and documented once every six months, last drill was conducted, December 4, 2015.
Licensee is current with CPR and First Aid which expires July 18, 2017. Assistant is current with CPR and First Aid which expires May 8, 2016.
The home has a current roster of the children. Licensee maintains the capacity specified on the license.
Licensee documents and maintains and updates records for children in care. Licensee provides the child's parent or representative with a copy of the Family Child Care Home notification of parents' rights.

Licensee stated that she does not provide Incidental Medical Services. Licensee was given information regarding Plan of Operation. All individuals subject to criminal record review have obtained criminal record clearance prior to working or residing in this home.
Licensee stated that there are no guns or ammunition in the home. Licensee provides liability insurance.

Today, no deficiencies cited under Title 22 Division 12.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Maria MuellerTELEPHONE: (805) 729-8797
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2015
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 1