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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414320
Report Date: 12/17/2019
Date Signed: 12/17/2019 05:11:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGNEW, DOROTHY & STEPHENS, CLEOTHAFACILITY NUMBER:
013414320
ADMINISTRATOR:AGNEW, DOROTHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 614-9156
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:14CENSUS: 9DATE:
12/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Dorothy AgnewTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Junell Chen and Caroline Colson arrived for an unannounced annual random and met with assistants Nadine Bastine and Abeer Nasser. Dorothy Agnew, licensee arrived during the inspection. All adults living and working in the home have a criminal record clearance. There are six infants and three preschool children present. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:00 AM to 5:30 PM.

ON LIMITS: The large play room located near the back of the home, kitchen with eat-in area, den, living room, dining room, and play room, and bathroom.

OFF LIMITS: The master bedroom and garage.

The isolation area is in the den.

The home is a split level home which is neat and clean with heating and ventilation for safety and comfort. The are a few stair that lead down to the play room. The fenced back yard is used for outdoor. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection. Licensee has 3A40BC fire extinguisher, carbon monoxide and smoke detector meet State Fire Marshall standards. There is no fireplace in the home. Per licensee, the heater vents are operable and is located on the ceiling. Per licensee, there are no firearms in the home. Per licensee, there is a pet dog in the home. All required licensing documents are posted and visible for public review.

***See LIC 809 C for Continuance***

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Junell ChenTELEPHONE: (510) 622-4035
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
VISIT DATE: 12/17/2019
NARRATIVE
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During the time of inspection, (2) children's files were reviewed. The facility roster was reviewed, and a copy obtained. The licensee is not in ratio today. The licensee's Pediatric CPR/First Aid certificate is current and expires 10/12/21. Licensee has current mandated reporter training completed on 7/03/18, and proof of required immunization records. Last disaster drill was logged on 02/05/19. Safe Sleep practices were discussed and new car seat laws were provided. Licensee was reminded that children are never to be left in a parked vehicle.

This facility is not providing Incidental Medical Services - IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417.


The following deficiencies were observed during today's inspection:

At 3:01PM, LPAs observed the facility is not in ratio today. There are 6 infants in care today.

At 3:20PM, LPAs observed the last disaster drill was conducted 02/05/19.

At 3:21PM, LPAs observed that the facility roster is not updated with the current children in care.

The attached type A deficiencies are being cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing. The attached type B deficiencies are being cited during this inspection.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

See LIC 809 D for deficiencies.

Exit interview conducted. Notice of Site visit was given during today's inspection and must be posted for 30 days. Appeal rights provided.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Junell ChenTELEPHONE: (510) 622-4035
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2019
Section Cited

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For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

(1) Twelve children, no more than four of whom may be infants; or
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This requirement was not met as evidence by: based on observation. LPAs observed there to be six infants and three preschoolers in care today. The facility is out of ratio. This poses an immediate health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Junell ChenTELEPHONE: (510) 622-4035
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2019
Section Cited

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102417(9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall
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be informed promptly of their duties as required in the plan. (A)Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement was not met as evidence by: based on observation. The last drill was conducted in 2/5/19. This is This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
12/24/2019
Section Cited

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102417 Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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This requirement was not met as evidence by: based on observation. LPAs observed missing facility roster. This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Junell ChenTELEPHONE: (510) 622-4035
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4