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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845375
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:18:23 PM


Document Has Been Signed on 06/14/2023 02:18 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:MITCHELL-FIELDER FAMILY CHILD CAREFACILITY NUMBER:
334845375
ADMINISTRATOR:DEBORAH MITCHELL-FIELDERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 227-6154
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:14CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Deborah Mitchell-FielderTIME COMPLETED:
02:30 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 AM to 6 PM

· Off-limit areas include: 2nd Floor, Kitchen, Garage, Formal Living Room, Formal Dining 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 tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children.

· All hazardous items are stored inaccessible to children

· Toxins are locked

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

SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 9


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: MITCHELL-FIELDER FAMILY CHILD CARE
FACILITY NUMBER: 334845375
VISIT DATE: 06/14/2023
NARRATIVE
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· Stairs are barricaded.

· Clean, safe and age-appropriate toys

· Current roster on file

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

· Documentation of fire and disaster drills on file – Last drill conducted on 12/15/23

· 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 - Grant Deed

· Children’s records are complete

· Employee’s records are not complete

· Mandated Reporter Training completed on 01/14/2022

· Pediatric CPR and First Aid Card expire on 02/24

· Health & Safety Certificate - completed on Health & Safety College credit 08/1992



· Resident and staff records were reviewed and all adults who require caregiver background checks have not 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 MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: MITCHELL-FIELDER FAMILY CHILD CARE
FACILITY NUMBER: 334845375
VISIT DATE: 06/14/2023
NARRATIVE
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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 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.

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 MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: MITCHELL-FIELDER FAMILY CHILD CARE
FACILITY NUMBER: 334845375
VISIT DATE: 06/14/2023
NARRATIVE
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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.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

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, Deborah Mitchell-Fielder. 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 MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 06/14/2023 02:18 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: MITCHELL-FIELDER FAMILY CHILD CARE
FACILITY NUMBER: 334845375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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 in ensuring Licensee's daughter who resides at the facility is clear and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee agrees to get her daughter finger print cleared and associated to the facility and submit proof to teh department by teh POC due date. LPA provided LIC 9163(LIVE SCAN) form.
Licensee was reminded that per California Health and Safety Code Section 1548(b), 1568.0822(b), 1569.49(b), 1596.99(b), or 1597.58(b, that there would be a $100.00 Civil Penalty per day for every day the plan of correction is late.
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: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 06/14/2023 02:18 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: MITCHELL-FIELDER FAMILY CHILD CARE
FACILITY NUMBER: 334845375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

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 interview and record review, the licensee did not comply with the section cited above in having documentation of immunization for S1 available for the department to review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee agrees to obtain documentation of - TB Test, MMR vaccine, TDAP vaccine, and flu vaccine for S1 and submit to the department by teh POC due date.
Licensee was reminded that per California Health and Safety Code Section 1548(b), 1568.0822(b), 1569.49(b), 1596.99(b), or 1597.58(b, that there would be a $100.00 Civil Penalty per day for every day the plan of correction is late.
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: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Sumayya HabeebullaTELEPHONE: 951-201-1991
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 9