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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009801
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:59:51 PM

Document Has Been Signed on 10/28/2021 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:MOONEY, ANN FCCHFACILITY NUMBER:
493009801
ADMINISTRATOR:ANN MOONEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 335-5259
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ann MooneyTIME COMPLETED:
01:15 PM
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A required annual inspection of the facility was conducted by Licensing Program Analyst (LPA), J. Velasco. During today’s inspection the home and grounds were toured. Licensee Ann Mooney (L1), staff Carsyn Hardy (S1), and staff Eileen Mooney (S2) were present in the home and supervising nine 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 8:00 a.m. - 4:00 p.m., Monday - Friday, year round. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the living room, toileting facility, and a large, fully fenced yard between the main home and fencing on the western side of the property. The entire upstairs of the main home, the kitchen and dining room, staircase, the barn, the workshop, sheds, multiple fields, the second home at the front of the property, and the garage are "off limits" to the day care children. These areas have been made inaccessible by door locks, locked gates, and fencing. The home was observed to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. L1's pediatric CPR and First Aid certifications were reviewed and expire in 11/23. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children in the locked garage and upper kitchen cupboard. L1 stated any poisons are kept in a high cupboard in the key locked garage. The home has heaters for heat and fans for cooling. LPA observed a working smoke detector, carbon monoxide detector, and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, documented in 10/2021. L1 stated there are no guns on premises, and none were observed during this inspection.

Continued on LIC 809-C.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801
VISIT DATE: 10/28/2021
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Continued from LIC 809.
The children use the yard as the outdoor play area, and the property is fully fenced. L1 stated there were no pools or other bodies of water, and none were observed. Five children's records were reviewed at 12:00 p.m., and current immunizations and Notification of Parent’s Rights forms were on file. Facility and personnel files were reviewed at 12:20 p.m. and contained necessary records. L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA discussed the safe sleep regulations with L1 and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed L1 of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. This facility provides Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with L1.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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