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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408320
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:50:57 PM


Document Has Been Signed on 05/25/2023 01:50 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:VAN VELZEN, MARTAFACILITY NUMBER:
073408320
ADMINISTRATOR:VAN VELZEN, MARTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 878-5795
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:14CENSUS: 6DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marta Van VelzenTIME COMPLETED:
02:30 PM
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On 05/25/2023 at 1:00 PM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced random inspection. LPA was greeted by fingerprint cleared assistants, Cailyn (Niven) Bothwell and Justine (Yanga) Malasavanh, who granted inspection authority to tour the facility. The licensee, Marta Van Velzen arrived shortly after. Also present for the inspection were 6 children in care, consisting of 2 infants and 4 preschoolers. Licensee states there are currently 12 children enrolled. Children’s and staff files were reviewed. 1 assistant did not have proof of immunity for measles in file (See 809D).

The children use the bathroom in the hallway, living room/napping room, classroom area, and backyard. There is a chicken coupe in the backyard, which is properly fenced and made inaccessible to children in care. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is the the hallway. The LPA toured all areas used by children.



Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were no fireplaces or open face heaters accessible to children. There were safe toys, play equipment, and materials observed for children. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 3A40BC fire extinguisher, working dual smoke alarm and carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on August 10, 2023 respectively.

LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was also advised that all infants up to 12 months of age should have the LIC 9227 form in their file.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: VAN VELZEN, MARTA
FACILITY NUMBER: 073408320
VISIT DATE: 05/25/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, 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

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

Licensee 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Marta Van Velzen.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/25/2023 01:50 PM - It Cannot Be Edited

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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: VAN VELZEN, MARTA
FACILITY NUMBER: 073408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above ensuring all staff have proof of immunity for measles in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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By 06/23/2023 send LPA proof of immunity for measles for staff
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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