185403612-6-5-2024-13-CC-SSIS-D5XTM8-20240605145044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 185403612
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:50:51 PM

Document Has Been Signed on 06/05/2024 02:50 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SALEM, DOROTHY FAMILY CHILD CARE HOME		FACILITY NUMBER:	185403612
ADMINISTRATOR/ DIRECTOR:	SALEM, DOROTHY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 253-3317
CITY:	JANESVILLE	STATE: CA	ZIP CODE:	96114
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 16	DATE:	06/05/2024
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:37 PM
MET WITH:	Dorothy Salem - Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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On 6/5/24 at 1:37pm, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Sydney Sims. At 2:15pm the home was toured inside and outside. The licensee and assistant were supervising Sixteen children, and not operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:30am to 6:00pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the down stairs, and master bedroom and were made inaccessible by baby gate and door knob cover. The children use the back porch and back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

Six children's records were reviewed at 1:51pm. Two staff records were reviewed at 2:09pm. There are currently two adults living in the home.

The following deficiencies were cited: Upon arrival Licensee stated that there is 16 children present and the facilities capacity is 14, Licensee is not maintaining safe sleep logs. (see LIC 809D):

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SALEM, DOROTHY FAMILY CHILD CARE HOME	FACILITY NUMBER: 185403612
	VISIT DATE: 06/05/2024

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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/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.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SALEM, DOROTHY FAMILY CHILD CARE HOME	FACILITY NUMBER: 185403612
	VISIT DATE: 06/05/2024

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Salem, Dorothy, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the licensee Dorothy Salem .

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2024 02:50 PM - It Cannot Be Edited

Created By: Sydney Sims On 06/05/2024 at 02:38 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SALEM, DOROTHY FAMILY CHILD CARE HOME	FACILITY NUMBER: 185403612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, by not mainting 15 minute safe sleep logs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	Plan of Correction
1 2 3 4	Licensee agrees to watch safe sleep video provided from the CCL website and write statement acknowledging the Licensee watched it. Licensee will do two days safe sleep logs for the infants in care and send copy of log to LPA Sims via email sydney.sims@dss.ca.gov

Type B

Section Cited

CCR

102416.5(a)

Staffing Ratio and Capacity

(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. 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, by proividing care for 16 children at one time which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	Plan of Correction
1 2 3 4	Licensee will write statement agreeing to not go over ratio, Licensee has created calendar to help prevent going over ratio. Licensee will send copy of statement to LPA Sims via email to sydney.sims@dss.ca.gov

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:

Megan Aviles

LICENSING EVALUATOR NAME:

Sydney Sims

LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

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