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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 163901684
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:09:46 PM


Document Has Been Signed on 01/10/2023 01:09 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:MOMBERGER, DAWN FAMILY CHILD CAREFACILITY NUMBER:
163901684
ADMINISTRATOR:MOMBERGER, DAWNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 904-6906
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY:14CENSUS: 7DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dawn MombergerTIME COMPLETED:
01:30 PM
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On 01/10/2023 Licensing Program Analyst (LPA) Nancy Her, conducted an unannounced Annual Required Inspection and was met by Licensee, Dawn Momberger. Days and hours of operation are Monday through Friday 7:00 am to 5:30 pm. The home has working telephone service and LPA confirmed the phone number is (559) 904-6906.

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, and family room are used for providing care and are accessible to children. 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. All other rooms are off-limits and made inaccessible by use of child safety gate. When LPA arrived, LPA observed that there was not a baby gate or door knob safety covers. LPA addressed this with Licensee. Licensee installed child safety gate during today’s inspection. The outdoor play area in the front yard is not fenced and there are no hazards to children present. Licensee ensures children are supervised at all times while outside. There are three dogs. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets. There is a swimming pool in the backyard that is not accessible to children. 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. 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. Safe toys and play equipment are observed.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684
VISIT DATE: 01/10/2023
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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 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. 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 03/29/2022. Licensee’s pediatric CPR/First Aid expires on 05/07/2024. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

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.

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 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.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684
VISIT DATE: 01/10/2023
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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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D)

Exit interview conducted and report was reviewed with the facility representative Dawn Momberger.

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

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/10/2023 01:09 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

a. Date.
b. Infant’s name.
c. Time of each 15-minute check.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA observed that Licensee did not have 15 minute check logs for infants that were between the ages of 12 months and 24 months old which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2023
Plan of Correction
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Licensee will physically check on sleeping infants every 15 minutes and keep documentation on safe sleep log. Licensee will submit copy of safe sleep log showing two weeks of documentation to Fresno Community Care Licensing by 01/27/2023.
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: Duane MatsubaraTELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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