Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503908818
Report Date: 02/10/2016
Date Signed 02/10/2016 02:23:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:PERSHALL, MELISSA FAMILY CHILD CAREFACILITY NUMBER:
503908818
ADMINISTRATOR:PERSHALL, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 869-5900
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:14CENSUS: 12DATE:
02/10/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant, Kayla BurciagoTIME COMPLETED:
02:45 PM
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(1)An unannounced Annual Random visit was conducted by LPA Kathie Campbell. Met by assistants, Kayla Burciago and Carli Jamison. Licensee returned during this visit. This is a large home family home. A tour of the home and grounds was given. Licensee is within capacity limit. There is an in ground pool which is surrounded with mesh fencing and property line fencing. The gate is self latching, self closing and opens away from the pool. Licensee understands the mesh fencing must remain in place during day care hours. Licensee stated there are no weapons kept at the home. Poisons are inaccessible and locked (no poisons are stored on premises). Medications/cleaning compounds and other harmful items are stored in inaccessible areas. The licensee stated the fireplace will not be used during day care hours. The home has operable fire extinguisher, smoke alarm and carbon monoxide detector. Safe toys, safe indoor and outdoor play areas, and a clean and orderly home with heating and ventilation was observed. The home is two stories and stairs are made inaccessible by using a child proof gate. The phone number was verified. Outdoor play area is fenced. Discussed children shall be supervised at all times. Off-limit rooms are made inaccessible by using child proof gates. Licensee is aware that any adults providing care and supervision or living in the home must be background cleared and LIS 531 was signed. Licensee maintains a copy of children's emergency information in children's files. Licensees CPR and First Aid training are current. Family pet, a small dog, was observed and is accessible to day care children. Licensee understands that she is responsible for child safety around pets at all times and hazards of pets around children were discussed. Fire drills are conducted at least every 6 months and documented. Children's roster was obtained. Postings are correct. Discussed that the licensee is responsible to stay current with regulations and forms through the CCLD web site (www.ccld.ca.gov).  Incidental Medical Services (IMS) was discussed. Licensee stated she is not administering medication has not decided to do so. Licensee stated she will send in an updated medical plan of operation prior to administering medication.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, there are no deficiencies are found during this visit: Exit interview was conducted. The licensee, Melissa Pershall was provided a copy of their appeal rights (LIC9058 12/15) and their signature on this form acknowledges receipt of this form.
NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)243-4588
LICENSING EVALUATOR NAME: Kathie CampbellTELEPHONE: (559) 341-4724
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2016
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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