313620693-11-15-2022-03-CC-LHAM-CL7RGD-20221115120035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313620693
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:02:20 PM

Document Has Been Signed on 11/15/2022 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	COSTA, CRISTINA		FACILITY NUMBER:	313620693
ADMINISTRATOR:	COSTA, CRISTINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 488-6233
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	14	CENSUS: 8	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Cristina Costa		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	All times are estimate on the report Licensing Program Analyst (LPA) Lea Habtom met with Licensee, Cristina Costa, for the purpose of an unannounced required 1-year inspection. At the time of LPA's arrival, around 9:45 am, licensee was the only adult present in the home. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed a total census of 8 children consisting of 2 infants over 12 months and 6 preschool children being supervised by licensee. The licensee's daughter/assistant arrived around 10:00 am. Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include master bedroom, master bathroom, son's room, kitchen, entire backyard and garage. During today's visit licensee requested that the son's room be taken off limits and daughter's room be placed off limits. Prior to today's visit, licensee was using an off limits room as a napping room. Off limits areas was updated to include master bedroom, master bathroom, daughter's room, kitchen, backyard and garage. Licensee 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. Licensee stated there are no weapons in the home. LPA did not observe bodies of water at the facility. Toxic and hazardous items are inaccessible to children. Fireplace is barricaded to prevent access by children. There are no stairs in the home. Outdoor play space is fenced. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated. At LPA reviewed children’s files. A current roster is being maintained and fire and disaster drills are documented. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires 10/2024, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 4/2024. Licensee's assistant/daughter mandated reporter training and immunization's could not be verified. (Report continues LIC809-C)

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea Habtom	TELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COSTA, CRISTINA	FACILITY NUMBER: 313620693
	VISIT DATE: 11/15/2022

NARRATIVE

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LPA observed one play yard at the facility. Play yards had loose objects liked stuffed animals and blankets. Licensee removed items once notified items are prohibited in the play yard. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

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 Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. 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)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http?//www.ada.gov/childqanda.htm

Title 22 Deficiency has been cited on the attached LIC 809-D. LPA Lea Habtom informed licensee Cristina Costa that this report dated November 15, 2022 document(s) 2 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Lea Habtom informed the licensee Cristina Costa to provide a copy of this licensing report dated November 15, 2022 that documents any Type A citation(s) 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. Appeal Rights given.

Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, regulations, current forms, Provider Information Notices (PINs), and to subscribe to quarterly updates. Exit interview conducted and report was reviewed with the licensee Cristina Costa. 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.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea Habtom	TELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2022 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COSTA, CRISTINA	FACILITY NUMBER: 313620693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.3(a)(6)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. 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 in that a room (son's room) stated as off limits was used as a napping room where an infant was napping which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	Licensee agreed to add son's room as an on limits room. LPA inspected the room and updated the off limits areas and made licensee aware that any changes to off limits area must be notified to licensing prior to use.

Type A

Section Cited

CCR

102416.5(e)

Staffing Ratio and Capacity

(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). 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 in that there were 8 children being supervised by licensee with no school age children which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	During the inspection, licensee's daughter/assistant arrived during the inspection. Licensee is aware to adhere to small capacity requirements when there is no assistant present.

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: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea Habtom	TELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 11/15/2022 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COSTA, CRISTINA	FACILITY NUMBER: 313620693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the play yard had a stuffed animal and blankets which poses a potential health, safety or personal rights risk to persons in care since the infant was not napping at the time.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	LPA notified licensee of sleep regulations and items prohibited in a crib/play yard & licensee immediatly removed the items.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the assistant/daughter did not have mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2022
	Plan of Correction
1 2 3 4	Licensee agreed to email LPA L. Habtom a copy of the ceriticate by POC date.

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: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea Habtom	TELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/15/2022 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COSTA, CRISTINA	FACILITY NUMBER: 313620693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in the assistant/daughter did not have proof of immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2022
	Plan of Correction
1 2 3 4	Licensee agreed to email LPA L. Habtom a copy of assistants/daughters immunization records by POC date.

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: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea Habtom	TELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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