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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233007654
Report Date: 04/05/2024
Date Signed: 04/05/2024 05:31:20 PM


Document Has Been Signed on 04/05/2024 05:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:DIAZ, TRACY FCCHFACILITY NUMBER:
233007654
ADMINISTRATOR:DIAZ, TRACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 671-3998
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:14CENSUS: 8DATE:
04/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Tracy DiazTIME COMPLETED:
05:38 PM
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A Required Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 4/5/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. 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.

During today’s inspection the home and grounds were toured. The Licensee was supervising eight children and was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicles. The facility’s operating hours are 7:30 AM to 5:15 PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the living room, the kitchen, the bathroom, the daycare room, the patio, and the back yard. The off-limits areas of the home are the three bedrooms, and the front yard and were made inaccessible by door locks. The home was at a comfortable indoor temperature. The children in care have access to age-appropriate toys and equipment. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification was current and expires in February 2025. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detector and a fully charged fire extinguisher rated at least 2A10BC. The Licensee stated that poisons, firearms, and ammunition are not stored on the premises and none were observed by LPA.


Continue to LIC 809-C.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DIAZ, TRACY FCCH
FACILITY NUMBER: 233007654
VISIT DATE: 04/05/2024
NARRATIVE
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On this date, 04/5/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. During the exit interview, the Licensee Tracy Diaz, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

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.



Exit interview conducted and report was reviewed with Tracy Diaz. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The following violations of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DIAZ, TRACY FCCH
FACILITY NUMBER: 233007654
VISIT DATE: 04/05/2024
NARRATIVE
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The open-face heater in the living room was not screened. LPA observed an infant, C1, sleeping in a play pen with a blanket. The licensee stated that she did not record the sleep checks for infants in care. There is no spa, pool, pond, or fountain observed on the premises and none shall be added without prior approval of the Licensing agency. The Licensee did not possess record of conducted disaster drills. The facility roster of the children in care was reviewed and appeared to be complete. LPA reviewed five children's records (C1-C5) at 4:13 PM which revealed that child 1 - 4's (C1-C4) I.D. and Emergency Information Cards were recorded on the LIC 601 form. LPA reviewed staff and personnel records at 4:01 PM which revealed that staff 1 (S1) did not possess proof of immunization against measles and pertussis and staff 2 (S2) did not possess current Mandated Reporter Training Certificate.

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.

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/.


Continue to LIC 809-C.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/05/2024 05:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: DIAZ, TRACY FCCH

FACILITY NUMBER: 233007654

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the heater in the living room was not screened which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Licensee stated she would put up a screen to block the heater and send a picture of the screen to LPA.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licenseedid not have record of disaster drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Licensee stated she would create a new disaster drill log and send a picture of a recorded drill to LPA.
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 04/05/2024 05:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: DIAZ, TRACY FCCH

FACILITY NUMBER: 233007654

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/05/2024

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, child 1(C1) was sleeping in a playpen with a blanket which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Licensee stated she would ensure that infants do not sleep with any objects in play pens.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewthe licensee stated she did not record 15 minute checks for infants when sleeping which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Licensee stated she would begin recording the sleep checks and send a picture of one week of completed checks to LPA.
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 04/05/2024 05:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: DIAZ, TRACY FCCH

FACILITY NUMBER: 233007654

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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2
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Based on record review, staff 2 (S2) did not possess a current manded reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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Licensee stated she would ensure that S2 obtains a current Mandated Reporter Training Certificate and send a copy to LPA.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff 1 (S1) did not posses proof of immunzation against mealses and pertussis which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2024
Plan of Correction
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3
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Licensee stated she would obtain proof of immunization against measles and pertussis and send a copy to LPA.
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7