Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 12/28/2016
Date Signed 12/28/2016 03:24:43 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: 3DATE:
12/28/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tracey Ann BornemanTIME COMPLETED:
03:40 PM
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(1) Licensing Program Analyst (LPA) Maria Mueller conducted an annual random visit and met with licensee, Tracey Ann Borneman. LPA observed 3 children in the home watching age appropriate television program. The home was toured inside and outside. The living room is used for day care. LPA observed age appropriate toys, games, books and furnishings. The bathroom is clean and free of toxins. The backyard is completely fenced, LPA observed play structure with sand cushioning, grass area, bike area and shade area. There are no bodies of water observed. Licensee stated that there are no guns or ammunition in the home.
The fire extinguisher was serviced May 16, 2016. There is a functioning carbon monoxide detector that meets statutory requirements. The smoke alarm was tested and was found operational. Licensee conducted and documented safety drills, last drill was conducted November 21, 2016.
Licensee is not providing Incidental Medical Services. 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
Children's roster reviewed. Child's file reviewed. Licensee is current with CPR and First Aid which expires July 18, 2017. Licensee is current with SB 792 immunization requirements. LPA gave licensee a handout "A Child Care Provider's Guide to Safe Sleep".
In the areas that were evaluated, no deficiencies were observed at the time of the visit.
LPA observed licensee post the Notice of Site Visit.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Maria MuellerTELEPHONE: (805) 729-8797
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2016
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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