Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455406533
Report Date: 09/07/2016
Date Signed 09/08/2016 07:44:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:LACK, KIMBERLY FAMILY CHILD CARE HOMEFACILITY NUMBER:
455406533
ADMINISTRATOR:LACK, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 510-1928
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:14CENSUS: 8DATE:
09/07/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Kimberly LackTIME COMPLETED:
01:05 PM
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(2) A visit was made to the facility by LPA Patricia Pacheco. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 2 adults living in the home.

During today’s visit the home and grounds were toured and the licensee was operating within the licensed capacity. Licensee stated normal operating hours are 7:30 am to 5:30 pm, Monday – Saturday. The floor plan was verified. Child care is primarily provided in a detached two-room building in the backyard. The home day care rooms appeared clean and orderly. There was a working telephone. The licensee has taken a course in Preventive Health Practices. The licensee's pediatric CPR and First Aid cards were current. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisons were locked in sheds in an adjacent fenced yard. There was a working smoke detector and fire extinguisher in the day care rooms. The licensee had a current roster of children in care and provided documentation of an emergency drill being conducted within the past six months. The licensee stated no firearms and/or other dangerous weapons are kept in the home and none were observed during today's visit. The licensee stated the backyard is used by children during outdoor activity time and it was completely fenced. All licensing reports are public information and must be made available upon request for at least three years.
Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's visit.
SUPERVISOR'S NAME: Jordan MonathTELEPHONE: (530) 895-5948
LICENSING EVALUATOR NAME: Patricia PachecoTELEPHONE: 530-895-5886
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2016
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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