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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008506
Report Date: 08/16/2023
Date Signed: 08/16/2023 02:08:29 PM


Document Has Been Signed on 08/16/2023 02:08 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:A PLACE OF MY OWNFACILITY NUMBER:
283008506
ADMINISTRATOR:SHANNON DANIELSFACILITY TYPE:
850
ADDRESS:2590 FIRST STREETTELEPHONE:
(707) 224-8667
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:52CENSUS: 32DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Shannon DanielsTIME COMPLETED:
02:15 PM
NARRATIVE
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An unannounced Case Management visit was made to the facility by Licensing Program Analyst (LPA) Mindy Mohr due to a reported incident of a Child (C1) who was handled inappropriately while in care by a Staff member (S1).

During today's case management visit LPA toured the facility, conducted interviews with six staff and three children and reviewed facility documents.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided.


LPA Mohr informed the Director to provide a copy of this licensing report dated 08/16/2023, that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

Exit interview conducted and report was reviewed with Director Shannon Daniels.


SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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Document Has Been Signed on 08/16/2023 02:08 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: A PLACE OF MY OWN
FACILITY NUMBER: 283008506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement was not met as evidenced by:
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D1 stated that S1's employment was terminated the following day. D1 stated that they will have a training on how to deal with frustrations and challenging behaviors with children.
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Based on interviews conducted S1 has handled a day care child in care in a rough manner, which poses an immediate health, safety and personal rights risk to the children in care.
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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda MohrTELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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