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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103900153
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:52:35 PM


Document Has Been Signed on 03/23/2022 04:52 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, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:CARMONA,PHYLLISFACILITY NUMBER:
103900153
ADMINISTRATOR:CARMONA,PHYLLISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 299-5549
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:14CENSUS: 7DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Licensee - Phyllis CarmonaTIME COMPLETED:
05:05 PM
NARRATIVE
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On 03/23/2023, Licensing Program Analyst (LPA), Luisa Gavoutian, conducted an unannounced Annual Inspection. LPA was greeted by Licensee Phyllis Carmona who accompanied LPA on a tour of the home, inside and outside, as shown on the facility sketches provided. Also present was a fingerprint-cleared assistant. Present during today’s inspection were seven children. The areas of the home that are accessible to the daycare children are the two daycare rooms, laundry room, bathroom, and fenced-off portion of the backyard. “Off-limits” rooms are made inaccessible by locks and latches.

No pets were observed during today's inspection. There are no bodies of water in this home. Firearms are locked and stored according to regulation; no ammunition present in the home. No poisons were observed during the inspection. There is no fireplace. There is a working fire extinguisher, which was last serviced on 07/02/2021. LPA tested the smoke detector and carbon monoxide indicator, which were both in working condition. The home has adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment were observed.

Adequate supervision is being provided during this inspection. LPA observed Child 1 napping in a play yard with a blanket and a pillow. LPA observed Child 1’s head was covered with the blanket. Licensee’s assistant removed the blanket and the pillow from the play yard. LPA discussed the safe sleep requirements and explained that once Child 1 transitions to a cot or a mat, then Child 1 can then use a pillow and blanket, but Child 1’s head must remain uncovered at all times, even if Child 1 sleeps on a cot or mat. During the staff interview, Licensee stated that Child 1 had a cough and parent asked if Child 1 can return to care if Child 1, who is under age two, wears a face mask and Licensee agreed. Furthermore, LPA observed Child 2 was napping with a face mask. Licensee stated that Child 2 had a cough, which is why Child 2 was wearing a face mask while sleeping. Licensee’s assistant removed the mask immediately. LPA informed Licensee that the COVID-19 safety guidelines as set forth by the California Department of Public Health state that masks should not be worn by any child under age two and any child who is sleeping. (Continued on LIC 809-C)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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 5


Document Has Been Signed on 03/23/2022 04:52 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, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: CARMONA,PHYLLIS
FACILITY NUMBER: 103900153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in Child 2 and Child 1 should not have worn face masks as described in LIC 809 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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Licensee's assistant immediately removed the face mask from Child 2. Licensee stated she shall review the COVID-19 guidelines for child care and PIN 21-29-CCP and submit a written statement explaining how she will ensure this deficiency does not occur in the future. This statement to be submitted to CCL by 03/24/2022.
Type A
Section Cited
CCR
102425(g)
(g) An infant’s head shall not be covered while sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Child 1's head was covered with a blanket while Child 1 was sleeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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Licensee's assistant immediately removed the blanket from Child 1's head and play yard. Licensee shall review the infant safe sleep regulations and shall submit a written statement describing how she will ensure the deficiency does not occur in the future. This statement to be submitted to CCL by 03/24/2022.

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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/23/2022 04:52 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, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: CARMONA,PHYLLIS
FACILITY NUMBER: 103900153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Child 1 was sleeping in a play yard with a blanket and pillow which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Licensee's assistant immediately removed the blanket and pillow from Child 1's play yard. Licensee shall review the infant safe sleep regulations and shall submit a written statement describing how she will ensure the deficiency does not occur in the future. This statement to be submitted to CCL by 04/25/2022.
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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: CARMONA,PHYLLIS
FACILITY NUMBER: 103900153
VISIT DATE: 03/23/2022
NARRATIVE
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Children are supervised when outside in the play area and there are no hazards to children present. Capacity as specified on the license is being maintained. Fire drills are conducted and documented at least once every six months. A current roster of children is maintained.

There is a working telephone and cellphone number was verified. LPA reviewed a sample of children’s files, which were all complete with emergency information as required. Licensee maintains documentation of immunizations for influenza, pertussis, and measles for herself and staff. Licensee’s Pediatric CPR/First Aid are current expiring on 04/10/2023. Licensee’s Mandated Reporter training certificate was completed on 05/03/2021. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advanced notice. Days and hours of operation are Monday – Friday; 7:30 a.m. – 5:30 p.m.

LPA & Licensee discussed the Community Care Licensing (CCL) website (www.ccld.ca.gov) which provides access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, Forms, and Regulations. Licensee stated she is receiving PINs and updates through email. LPA discussed infant items permitted in Family Child Care Homes and left a visual handout. LPA provided Licensee with the “Effects of Lead Exposure” brochure in accordance with AB 2370, Chapter 676, Statutes of 2018.

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. (Continued on LIC 809-C)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: CARMONA,PHYLLIS
FACILITY NUMBER: 103900153
VISIT DATE: 03/23/2022
NARRATIVE
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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’

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Exit interview conducted and report was reviewed with the Licensee Phyllis Carmona.

LPA Luisa Gavoutian informed licensee Phyllis Carmona that this report dated 03/23/2022 documents two Type A citations which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Luisa Gavoutian informed the licensee to provide a copy of this licensing report dated 03/23/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.



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 inspectionprocess@dss.ca.gov. 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.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5