334830699-10-12-2022-10-CC-SHAA-CK5RZP-20221012132817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334830699
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:28:55 PM

Document Has Been Signed on 10/12/2022 01:28 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME:	VOSS FAMILY CHILD CARE		FACILITY NUMBER:	334830699
ADMINISTRATOR:	VOSS, HELEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(951) 242-2368
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	14	CENSUS: 2	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Helen Voss		TIME COMPLETED:	01:45 PM

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On date and time listed, Licensing Program Analyst (LPA) Sumayya Habeebulla arrived at the facility to conduct an annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: Mon-Fri, 6:30 AM to 6:30 PM

· Off-limit areas include: 2nd Floor, Kitchen, Formal Living & Dining Room, Laundry Room

· The facility is licensed to have no more than 14 children as a large FCCH and is operating within the licensed capacity and appropriate ratios.

· Appropriate supervision provided during this inspection

· A working telephone is present, and the current phone number is on file

· A fully charged fire extinguisher (2A:10BC) was observed. A smoke detector and carbon monoxide detector were present and was not tested by the Licensee during this inspection since children were napping.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
	VISIT DATE: 10/12/2022

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· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Stairs are barricaded

· Clean, safe and age appropriate toys

· Current roster is on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are not posted

· Documentation of fire and disaster drills on file – Last drill conducted on 06/20/2019

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Verification of control of property on file - Property Tax Bill

· Children’s records are not complete

· Employee’s records are not complete

· Mandated Reporter Training expired on 11/30/2020

· Pediatric CPR and First Aid Card expire on 02/09/2022

· Health & Safety Certificate - completed on 06/28/2009

· Resident and staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
	VISIT DATE: 10/12/2022

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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.

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
	VISIT DATE: 10/12/2022

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Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

See LIC809-D for cited deficiencies

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.

An exit interview was conducted, and this report was reviewed with the licensee Helen Voss. Appeal rights were discussed and provided during the exit interview.

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

SUPERVISOR'S NAME: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in conducting a Fire Drill every 6 months and recording the drill which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to conduct fire drills every 6 months and submit the proof to the department along with a written statement by the POC due date.

Type B

Section Cited

CCR

102425(h)

Infant Safe Sleep

Car seats shall only be used for transportation purposes and shall not be used for sleeping. 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 placing the infant in the play pen for nap time, the infant was sleeping in a car seat during the visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	LIcensee agrees to submit a written statement after reviewing safe sleep regulations that no infant will be let to sleep on a car seat at the facility by the POC due 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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(1)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in keeping a sleep log for th einfant in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to create a sleep log and submit a completed sleep log to the Department by the POC due date for the infant in care.

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 renewing her Mandated Reporter Training and for her Assistant poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to renew her and her Assistant's Mandated reporter Training and submit the certificates it to the Department by the POC due 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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(d)

Personnel Records

(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. 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 in having all personnel Records available at the facility for the Department to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit all forms for her assistant to the Department by the POC due date.

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 record review, the licensee did not comply with the section cited above in 2 out of 2 children in care did not have LIC 700 in their file for the department to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agress to submit a completed LIC 700 to the Department for C1 & C2 by the POC due 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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. 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 having immunization records for C1 & C2 available for review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of C1 & C2's immunization record by the POC due 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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). 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 having a signed and completed LIC 995A for C1 & C2 available for review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of the signed and completed lic 995A to the Department by the POC due date for C1 & C2.

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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2022 01:28 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOSS FAMILY CHILD CARE	FACILITY NUMBER: 334830699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

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 record review, the licensee did not comply with the section cited above in having a sleep log for C1 available for review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2022
	Plan of Correction
1 2 3 4	Licensee agrees to complete a sleep log for C1 and submit the completed sleep log by the POC due 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: Carlos Martinez	TELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya Habeebulla	TELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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