313621518-12-13-2021-03-CC-ABLI-C9NQSN-20211213112549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313621518
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:25:58 AM

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:	GRAY, DECEMBER		FACILITY NUMBER:	313621518
ADMINISTRATOR:	GRAY, DECEMBER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 204-9281
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	14	CENSUS: 9	DATE:	12/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	December Gray		TIME COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, December Gray, for the purpose of an unannounced required 1-year inspection. Prior to entry into the home, A COVID-19 risk assessment was conducted with licensee at the door. The licensee's husband and assistant were also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. At 9:45.m. LPA observed a total census of 9 children including 1 infant over 12 months, and 8 preschool children. At 9:50 a.m., 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 upstairs 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. There is an above ground spa in the backyard which was observed covered and locked on all four sides. Toxic and hazardous items are inaccessible to children. Weapons were observed stored and locked. Fireplace is barricaded to prevent access by children. Stairs were barricaded to prevent access when children under 5 are present. 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 10:15am, LPA reviewed children’s files and observed immunization records and emergency contact information. A current roster is being maintained and fire and disaster drills are documented but need to be updated at least once every six months. 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 5/2023, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 6/2023. (Report continues LIC809-C)

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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: GRAY, DECEMBER	FACILITY NUMBER: 313621518
	VISIT DATE: 12/13/2021

NARRATIVE

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LPA observed one play yards at the facility. Play yards were free of loose objects. 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 [or facility representative] 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 [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

LPA verified that the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.

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

Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information.

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

Exit interview conducted and report was reviewed with the licensee, December Gray

Appeal Rights were given to licensee with a copy of this report.

Title 22 deficiencies are noted on the subsequent page of this report LIC 809-D. To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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: GRAY, DECEMBER	FACILITY NUMBER: 313621518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995

Commencing September1, 2016 a person shall not be employed nor volunteer at a day care center or family day care home if she or he has not been immunized against influenze, pertussis and measles. This requirement is not met as evidenced by: assistant Angela did not have proof of measles immunization.
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above when Anglela Clard did not have proof of measle which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2021
	Plan of Correction
1 2 3 4	Licensee shall submit to LPA proof of measles immunization for assistant, Angela. This shall be done by plan of corection date of 12/27/21. LIcensee can fax, mail or email LPA with the correction.

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: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC809 (FAS) - (06/04)

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