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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619733
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:01:43 AM


Document Has Been Signed on 12/14/2023 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ROBYN, JESSICAFACILITY NUMBER:
293619733
ADMINISTRATOR:JESSICA ROBYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 446-6192
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 0DATE:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Arrin RobynTIME COMPLETED:
11:10 AM
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At 9:40am on 12/14/2023, Licensing Program Analyst (LPA) Matthew Gallo met with licensee's husband, Arrin Robyn (AR), for a case management meeting regarding the recent death of licensee and plans to move the license to AR's name. Facility is not currently operating and today's census included 0 children.

During today's visit, LPA reviewed remaining steps to finalize changing the name of the license, administrative responsibilities of a facility, and conducted a health and safety inspection in all areas accessible to children. Off-limits areas include master bedroom and garage. AR acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per AR, there are no weapons in the home and LPA did not observe bodies of water at the facility. Toxic and hazardous items are inaccessible to children. There are no stairs in the home. Outdoor play space is fenced.

AR 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.

No children are currently enrolled, and LPA reviewed all documents and forms AR will need to collect from parents and keep on file. LPA further reviewed documents and forms licensee and staff must keep on file regarding the facility and its operations. Current CPR and First Aid certification for AR was verified and expires 4/2024, and AB1207 Mandated Reporter Training was verified and expires 10/2025. AR understands that these two certificates must be renewed every two years.

Report continues on 809-C

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROBYN, JESSICA
FACILITY NUMBER: 293619733
VISIT DATE: 12/14/2023
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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-andresources/safe-sleep as an additional resource. LPA also informed facility representative 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, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

AR 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.

AR stated they intend to resume providing care after January 1st. LPA will remain in conversation with AR to finalize the process of transferring the license into their name.

No deficiencies were cited during today's inspection

Exit interview conducted and report was reviewed with facility representative Arrin Robyn (AR). A notice of site visit was given and must remain posted for 30 days. During the exit interview, AR confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.





SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2