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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844834
Report Date: 03/19/2024
Date Signed: 03/20/2024 12:19:18 PM


Document Has Been Signed on 03/20/2024 12:19 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:ADAMS FAMILY CHILD CAREFACILITY NUMBER:
334844834
ADMINISTRATOR:ADAMS,DONISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 430-5012
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY:14CENSUS: 7DATE:
03/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Donisha AdamsTIME COMPLETED:
01:05 PM
NARRATIVE
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On March 19, 2024 at 10:55 am, Licensing Program Analyst (LPA) Jessica Rubio arrived at the facility to conduct an annual inspection as part of a compliance review. LPA met with Licensee Donisha Adams toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:

· Normal days and hours of operation are: Monday through Friday 6:30 am to 6:00 pm

· Off-limit areas include: Entire second story, downstairs bedroom and garage.

· The facility is licensed to have no more than 14 children as a large family child care home and is operating within the licensed capacity and appropriate ratios. LPA observed seven children in care with a licensee and one assistant providing care.


· Appropriate supervision was being 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 tested by the Licensee during this inspection.

· All hazardous items are stored inaccessible to children.

· Toxins are locked and inaccessible to children in care.

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

· Stairs are barricaded

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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 5


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: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 334844834
VISIT DATE: 03/19/2024
NARRATIVE
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· Clean, safe, and age-appropriate toys are provided

· Current roster on file

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills are on file – Last drill was conducted on 1/10/2024.

· There is an in ground pool located in the backyard. The pool is surrounded by vinyl perimeter fencing and 5' high mesh fencing. The mesh fencing has a gate however, the gate was not closing and self-latching properly. A citation will be issued.

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 is on file

· LPA reviewed five children’s files. All children’s records were complete.

· LPA reviewed one employee file. Assistant was missing documentation of immunizations. A citation will be issued.

· Licensee’s Mandated Reporter Training expires on 5/2024

· Licensee’s Pediatric CPR and First Aid Card expires on 8/2025

· Licensee completed Health & Safety Certificate on 10/8/2017


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

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 them 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/process.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 334844834
VISIT DATE: 03/19/2024
NARRATIVE
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Licensee 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.

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, available at: https://www.ada.gov/resources/child-care-centers/

Licensee 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.

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

On-line Licensing forms & regulations for a Child Care Center can be obtained on the Department’s website: www.ccld.ca.gov. Additionally, there is a link to “Receive Important Updates” located on the right side of the page, immediately above 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: 951-782-4200

The facility is being cited for Title 22 Regulations and Health & Safety Code. See LIC809-D for cited deficiencies.
During the exit interview, the Licensee Donisha Adams, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
An exit interview was conducted, and this report was reviewed with the Licensee Donisha Adams. 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: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/20/2024 12:19 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: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 334844834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)(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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the pool gate is not working properly and and self-latching which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee stated that the pool gate would be repaired and proof provided to LPA.

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: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/20/2024 12:19 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: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 334844834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as assistant did not have documentation of imunizations on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee stated she will get records on file and provide to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5