Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455406533
Report Date: 01/08/2019
Date Signed 01/08/2019 11:39:48 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: 11DATE:
01/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Kimberly LackTIME COMPLETED:
11:45 AM
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An inspection was conducted at the facility by Licensing Program Analysts (LPA), Mikah Martinez and Patricia Pacheco. A review of staff records on 01/08/19 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 currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee's two assistants were supervising 11 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30 am to 5:30 pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. Day care is primarily provided in the detached day care room that is equipped with a kitchenette and bathroom. There are safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 12/16/19. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. Poisons are locked in the detached shed. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Five children's records were reviewed at approximately 11:20 am; required emergency information was observed to be on file. Child 1 and 2 did not have evidence of required immunization records in file. The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Patricia PachecoTELEPHONE: 530-895-5886
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2019
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: LACK, KIMBERLY FAMILY CHILD CARE HOME
FACILITY NUMBER: 455406533
VISIT DATE: 01/08/2019
NARRATIVE
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provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. 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.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Patricia PachecoTELEPHONE: 530-895-5886
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 455406533
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2019
Section Cited
CCR
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by: based on record review, the licensee failed to maintain immunization records for Child 1 and 2. This poses a potential health and safety risk to children in care.
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The licensee agrees to maintain updated immunization records for all children in care. The licensee agrees to submit copies of immunization records for Child 1 and 2 by 01/18/19.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Patricia PachecoTELEPHONE: 530-895-5886
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2019
LIC809 (FAS) - (06/04)
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