Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 01/02/2018
Date Signed 01/02/2018 10:16:09 AM

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: 6DATE:
01/02/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tracey BornemanTIME COMPLETED:
10:30 AM
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(2) Licensing Program Analysts (LPAs) Maria Mueller and Gigi Reyes conducted an annual random visit and met with licensee, Tracey Borneman. The home was toured inside and outside. The home was toured inside and outside. LPAs observed 6 children in the home. The living room, play room area, dining room area, and kitchen area are accessible to children. The garage and bedrooms are off limits to children. The bathroom was found clean and free of toxins.
The outdoor play area is completely fenced, LPAs observed age appropriate toys, bikes, play structure with sand cushioning, bike area, grass area and shade area. There are no bodies of water observed.

The fire extinguisher was serviced July 25, 2017. The smoke alarm / carbon monoxide detector was tested and was found operational. Licensee is current with CPR and First Aid which expires April 25, 2017. The safety drills were conducted and documented, last drill was conducted December 13, 2017. Licensee is current with immunization requirements per SB 792. Children's roster re

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

In areas evaluated, no deficiencies observed.

LPAs 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: 01/02/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2018
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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