163901684-1-10-2022-04-CC-ROCA-CAJS6F-20220110123553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 163901684
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:36:10 PM

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:	MOMBERGER, DAWN FAMILY CHILD CARE		FACILITY NUMBER:	163901684
ADMINISTRATOR:	MOMBERGER, DAWN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 925-1680
CITY:	LEMOORE	STATE: CA	ZIP CODE:	93245
CAPACITY:	14	CENSUS: 10	DATE:	01/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Dawn Momberger		TIME COMPLETED:	01:00 PM

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On 1/10/2021 Licensing Program Analyst (LPA), Ruby Ocegueda conducted an unannounced Annual Required Inspection and was met by Licensee, Dawn Momberger. Also present was Staff #1 (S1). Days and hours of operation are 7:00 AM – 5:30 PM. Before entering, LPA conducted a Covid-19 health screening.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the kitchen, back bathroom (connected to family room), dining room, living room, family room are used for providing care and are accessible to children. LPA discussed accessible rooms and rooms that were supposed to be off limits. LPA observed the following, crafting supplies, books, games, and paper goods on the kitchen table. In the kitchen, LPA observed that the counters were covered with kitchen items, (food products, glassware, and plastic kitchen items). LPA addressed these observations with licensee and explained that surfaces should be kept clean and orderly per the regulation. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises. Firearms and ammunition are stored and locked separately. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Toys and play equipment were inspected today. Some of the toys inspected in the family room were dusty and or had smudging. Some of the toys were used for outside play and had dirt trapped in them. The child size chairs had dark areas that covered the entirety of the chairs. There was a play rug that was observed in the family room that had stains and had other dark areas that covered the rug. Licensee confirmed the observations and stated she could clean and wash the items. The home has working telephone service and LPA confirmed the phone number is (559) 904-6906.

Report continued on 809-C

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE	FACILITY NUMBER: 163901684
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(b)

Operation of A Family Child Care Home

(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed the following: in the dining room, there were craft supplies, games, and books cluttered on the table and kitchen items (cups, plastic wear, food) that covered kitchen counter. In the family room, there were multiple toys, children's chairs that were dusty and/or had dark smudges. The glass doors in the family room also had fingerprints and dark smudges. A play rug in the family room also had many stains and was dirty. Children have acess to the above named areas. Licensee confirmed the observations today. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	Licensee stated she would wipe and clean the toys, wash the carpet, clean the glass windows, clear and clean her kitchen countertops and clean and declutter the kitchen table. LPA discussed the regulation above, reminding licensee that her home (including toys, furntinure and walls, windows) should be kept clean and orderly per the regulation above. Licensee will submit proof of correction by POC date 2/8/2022.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above. Licensee had expired Mandated Reporter Training (10/2021) and assistant #1 did not have training completed. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/08/2022
	Plan of Correction
1 2 3 4	Licensee stated that she did not know that AB1207 Mandated Reporter Training was required every two years and did not know that assistant required the training. LPA reviewed the regulation above and encouraged licensee to review ccld.ca.gov website for guidance or reach our Department should she have any questions regarding requirements. Plan of Correction to be submitted by POC date : 2/8/2022.

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: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE	FACILITY NUMBER: 163901684
	VISIT DATE: 01/10/2022

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LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes. Licensee was advised of requirement to document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing for infants of up to 24 months of age. Licensee had only logged infant sleep for up to 12 months. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Licensee uses the front yard for outside play which is not fenced, however stated she provides 100 percent supervision while they play in the front yard. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 10/2019 and was expired. Assistant #1 had not completed required Mandated Reporter Training. Licensee’s pediatric CPR/First Aid expires on 7/11/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

Report continued to page 809-C

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: MOMBERGER, DAWN FAMILY CHILD CARE	FACILITY NUMBER: 163901684
	VISIT DATE: 01/10/2022

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LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC809 (FAS) - (06/04)

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