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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310810
Report Date: 09/27/2023
Date Signed: 09/27/2023 12:54:46 PM

Document Has Been Signed on 09/27/2023 12:54 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KEOUGH-SOMMA, GINAFACILITY NUMBER:
304310810
ADMINISTRATOR:KEOUGH-SOMMA, GINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 235-7946
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Gina K Somma TIME COMPLETED:
01:30 PM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Bootorabi.
The Facility Day care hours are 7:30 am-5:30 pm, Monday through Friday stated by the licensee.

Census: Infants: 2 Children Over Two: 3 School Age: 0
Adults Working Directly with Children: 1 Other Adults: 1

During today’s inspection, LPA observed children playing in the living room area. The licensee had 1 infant in a high chair, 3 other children playing with toys in the living room. During the inspection another child arrived for drop off shortly after.

Posted Requirements were reviewed during today’s visit. Upon arrival, the LPA verified that the following
documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’
Rights, and LIC 9148 Earthquake Preparedness. LPA provided a consultation regarding documents that must be in a prominent and publicly accessible.

Inside Tour: The LPA and licensee toured the facility inside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility sketch were made off-limits by baby safety gates in the following areas, stairs and by closed doors. There is a fireplace in the great room screened by a metal gate and mesh screen.
The licensee stated the children's primary care and play areas consist of the living room and great room. The licensee stated that children nap in the nap room in cribs and great room in mats. The licensee stated children eat in the living room on a child size table. The LPA and licensee toured the living room, kitchen, bathroom, and great room. Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available to children were not observed to be accessible to children in care. Floors, equipment, and ....
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 09/27/2023
NARRATIVE
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furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary.

The licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

Napping Area: The licensee washes soiled blankets in her home and provides all bedding.

The home has some age-appropriate toys for the ages served in the living room.

Diapering occurs in the napping room and children use the bathroom across from the napping room. Currently the bathroom does not have a hand washing station due to a plumbing issue and licensee stated that children wash their hands in the kitchen.

The location & functioning of the carbon monoxide, smoke detector, and fire extinguisher were
reviewed with the license. The fire extinguisher is under the sink in the kitchen and marked full. The smoke detector and carbon monoxide was tested and functional.

Outdoors: There are bodies of water (pool/hot tub) present at the home. The hot tub and pool are gated.
The facility’s outdoor grounds are safe, sanitary, and in good repair. LPA observed some children pretend home x2, art station and water play station (empty). The licensee stated that children do not go outdoors without outdoor supervision by her.

Records Reviewed: The LPA requested to review the LIC 610A Emergency Disaster Plan, Verification of
Disaster and Fire Drills, and LIC 9040 Facility Roster. The LPA reminded the licensee of the importance of keeping documents up to date. The licensee did not have an updated LIC 9040 or a drill log for review. A consultation was provided.

Personnel Records:The LPA requested to review 1 of 1 records of adults working directly with children. The following documents were requested for review CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate. The LPA observed 0 of 1 completed files. A consultation was provided.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 09/27/2023
NARRATIVE
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Children’s Records Reviewed: The LPA requested complete children’s records of 5 of 5 children
enrolled. Children's records were reviewed, and there was not a separate, complete, and current record for each child. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identification and Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. The children’s records were (not) complete currently. A consultation was provided due to licensee not having 2 complete files for children, and immunization records not updated. A consultation was provided.

Individual Sleep Plans : The LPA observed 1 infants from 0-24 months. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. LPA observed and reviewed 0 of 1 LIC 9227 Individual Infant Sleeping Plan in children’s files.

Sleep Logs: Staff shall physically check on sleeping infants every 15 minutes and document the following: 1. Labored breathing. 2. Signs of distress, which include but is not limited to flushed skin color, increase in body temperature, and restlessness. 3. Infants up to 12 months of age who are sleeping in a position other than on their back. The licensee provided 0 of 1 sleep logs of children 0 – 24 months.

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.

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be
added to an email list to receive Community Care Licensing Important Notifications from the above website
and selecting Receive Important Updates:
https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 09/27/2023
NARRATIVE
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Family childcare, home providers, have an important role in protecting the health and safety of children. Watch these brief, informative videos to learn more about putting Licensing regulations and requirements into practice. https://ccld.childcarevideos.org/family-child-care-providers/

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/

MyChildCarePlan.org: Family Child Care Homes 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. www.mychildcareplan.org


The licensee understands they must be present in the facility and must ensure children in care are always
supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from
the facility, arrangements must be made for a qualified substitute adult to care for and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances,
immunization's, Pediatric CPR/First Aid, and mandated reporter training.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12
were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 102421(a), 102421(b), 102417(g)(9)(A)1, 102425(j)(2), 102417(g)(7), 102417(g)(8), 102425(c), 102425(c)(2)

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day and shall provide them to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt of the Proof of Correction for 30 consecutive days.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 09/27/2023
NARRATIVE
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An exit interview was conducted with Gina K Somma . Appeal Rights were explained. Family Child Care Homes During the exit interview, the LICENSEE Gina confirmed that there are no Registered Sex Offenders living in the facility.

The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the regional manager at the address listed above.

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

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 .

End of Report

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of not having children records for C4 and C5 which poses an immediate health, safety risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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The licensee stated that she has already began communication with families to complete the files of the children.
Type A
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having an emergeny information card for C4 and C5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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The licensee will ensure that the families provided copies of the emergency card information by tomorrow.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


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Page: 6 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
N/A licensee had a emergency disaster plan. A consultation was provided to update the form.
POC Due Date: 09/27/2023
Plan of Correction
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N/A
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


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Page: 7 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)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: (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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having documentation for drill logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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2
3
4
The licensee stated that they would be completing the fire drill and logging it today.

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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


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Page: 8 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by means of not having sleep logs available for review for infant enrolled which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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2
3
4
The licensee will begin logging and observing children every 15 min.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of not having updated immunization records for children enrolled in the program which poses/posed a potential health, safety or personal rights risk to persons in care. LPA provided a resource to obtain records. CA Vaccination Records website.
POC Due Date: 09/27/2023
Plan of Correction
1
2
3
4
The licensee stated they would be contacting the families to ensure they provide copies of updated immunization records.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 9 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of not having a complete emergency information cared for C4 and C5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
1
2
3
4
The licensee stated she will be completing files for children by Friday 9/29/2023 and will be sending LPA an email once completed.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of not having a roster for children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
1
2
3
4
The licensee completed a roster for children during the visit and will be updating it with further information as files get completed.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 10 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having a LIC 9227 available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
1
2
3
4
The licensee will provide the document to the family to complete by tomorrow.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by means of not maintaning a LIC9227 for infants in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
1
2
3
4
The licensee stated she would keep documents in order and available to review.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 11 of 18
Document Has Been Signed on 09/27/2023 12:54 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/27/2023 at 11:27 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of not having an infant file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
1
2
3
4
The licensee stated she will begin doing checks today and documenting.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 12 of 18