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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617786
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:17:31 PM


Document Has Been Signed on 01/18/2023 04:17 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:GIUSTI-CHAVES, LOTTYFACILITY NUMBER:
343617786
ADMINISTRATOR:GIUSTI-CHAVES, LOTTYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 628-7659
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 10DATE:
01/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cassandra LindseyTIME COMPLETED:
04:30 PM
NARRATIVE
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On 01/18/2023, Licensing Program Analyst Katy Maestas (LPA) conducted a field visit to the Family Childcare Home (FCCH). LPA arrived at the FCCH and was met by Aide Cassandra Lindsey (A1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA toured the FCCH and observed 2 infants and 8 children being supervised by 2 adults. LPA determined through accessing Guardian that all required adults were background cleared.
During the inspection, LPA observed an infant under 12 months old and another infant under 24 months old both sleeping in play pens with blankets and full-sized pillows. As a result, a Type A deficiency was cited on subsequent 809D page. A1 understands that all parents or authorized representatives currently enrolled are required to sign the LIC 9224 and all parents who enroll for up to one year must sign the LIC 9224. This form is to be kept in the child's file and available for the Department's review.
An exit interview was conducted and the report was reviewed with A1. Licensee Appeal Rights were provided. A Notice of Site visit was posted by LPA 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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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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Document Has Been Signed on 01/18/2023 04:17 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: GIUSTI-CHAVES, LOTTY
FACILITY NUMBER: 343617786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2023
Section Cited

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...(b) Cribs or play yards shall be free from all loose articles and objects.
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All staff members will read PINS related to Safe Sleep Regulations. Safe Sleep posters will be displayed. All articles will immedialty be removed from cribs and play pens. LPA will be emailed a list of all staff members who read the Safe Sleep material provided by LPA
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and photographs of empty play pens mby 01/19/2023.

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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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