173008755-2-3-2020-01-CC-NCUM-BLFVF7-20200203152329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 173008755
Report Date: 02/03/2020
Date Signed: 02/03/2020 03:23:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	BLOCKER, SHERRI FCCH		FACILITY NUMBER:	173008755
ADMINISTRATOR:	BLOCKER, SHERRI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 413-3106
CITY:	LAKEPORT	STATE: CA	ZIP CODE:	95453
CAPACITY:	14	CENSUS: 8	DATE:	02/03/2020
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Sherri Blocker, Licensee		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) N. Cunningham made an unannounced Plan of Correction (POC) inspection to the facility to confirm infants are sleeping in pack-n-plays. On 01/24/20, the Licensee was cited a Type A citation for not providing a safe sleep environment for Child 1. The Licensee corrected the citation by setting up a pack-n-play for Child 1. Today at approximately 10:45 a.m., LPA observed Child 1 in a swing with her eyes closed. The Licensee stated Child 1 was awake and closed her eyes when she went to answer the door and let LPA Cunningham in. LPA observed one pack-n-play set up and two infants (Child 1 - Child 2) in care. The Licensee stated Child 1 sleeps in her arms because she is unable to sleep when she is not being held and Child 2 sleeps in the pack-n-play. The Licensee stated it is difficult to hold Child 1 and provide care for the other children. LPA and Licensee discussed other sleeping options for Child 1 so the Licensee can attend to the other children in care. During todays visit, the Licensee put on a child carrier backpack and placed Child 1 into the carrier so the Licensee could use her arms and hands. At 3:00 pm, the Licensee removed personal belongings out of a second pack-n-play and moved it from her bedroom closet into the playroom and set it up for Child 1 to use. LPA photographed the second pack-n-play set up in the play room. LPA Cunningham discussed infant safe sleep procedures. The Licensee stated she provided Child 1's parent a copy of the Infant Safe Sleep Brochure. The Licensee stated she is working with Child 1's parent to provide a similar sleep environment at Child 1's home so Child 1 will be able to sleep better at the Licensee's home. LPA reminded the Licensee and Staff 1 that infants need to sleep on a flat surface with nothing in the pack-n-play. At 10:45am, LPA observed the 809 issued on 01/24/20 posted on the front door; the 809-D issued on 01/24/20 was not posted, as well as the 01/24/20 Notice of Site Visit or the Letter of Deficiency Citations Cleared. During LPAs visit, the License moved the postings to the front window. At 2:50 p.m., LPA observed the 01/24/20 809-D, 01/24/20 Notice of Site Visit, Letter of Deficiency Citations Cleared and 02/03/20 Notice of Site Visit. LPA photographed the notices posted on the front window.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette Cunningham	TELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BLOCKER, SHERRI FCCH	FACILITY NUMBER: 173008755
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/06/2020 Section Cited	1 2 3 4 5 6 7	Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services.This requirement is not met as evidenced by: On 02-03-20 at 10:45am and 11:35am, LPA observed the 809 report posted on the front door. The 809-D
	8 9 10 11 12 13 14	page, Notice of Site Visit and Letter of Deficiency Citations Cleared were not posted. At 11:40am, the Licensee stated she did not post the 01/24/20 809-D, 01/24/20 Notice of Site visit or Letter of Deficiency Citations Cleared. At 2:50, LPA reviewed children's files and noted they did not contain LIC9224. At 11:30am, The Licensee stated she provided the LIC9224 to parents but has not receive any forms back with signature. This poses a potential risk to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette Cunningham	TELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BLOCKER, SHERRI FCCH	FACILITY NUMBER: 173008755
	VISIT DATE: 02/03/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Licensee stated she left Acknowledgement of Licensing Reports (LIC 9224) in each child's cubbies. The Licensee stated she informed all parents she received a citation on 01/24/20. As of today, the Licensee has not received a signed LIC 9224 from any parents. At 2:30 p.m., LPA conducted children's records review and LPA observed that the children's records do not have the LIC 9224 form, with full parent signatures. LPA provided the Licensee with several copies of the LIC 9224 forms and consulted with the Licensee about obtaining full parent signatures on the LIC 9224.

LPA and Licensee discussed the Technical Support Program (TSP) which provides additional support regarding Title 22 regulations and Safe Sleep Environments. Licensee agrees to proceed with services offered under the TSP.

This report was reviewed and discussed with the Licensee. Notice of Site Visit shall be posted for 30 days from today's visit. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette Cunningham	TELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3