343621006-12-17-2021-03-CC-ATIY-C9SVRP-20211217154016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343621006
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:40:27 PM

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:	STEPHENS, THEONIA		FACILITY NUMBER:	343621006
ADMINISTRATOR:	STEPHENS, THEONIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 822-1048
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95838
CAPACITY:	14	CENSUS: 6	DATE:	12/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Theonia Stephens		TIME COMPLETED:	04:00 PM

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	On December 17, 2021 at 1:45 PM, Licensing Program Analysts (LPAs) Alize Tillery and Josiah Gathing met with licensee Theonia Stephens for the purpose of an annual required 1 year inspection. The facility’s days and hours of operation are Monday - Friday from 7:00 AM to 6:00 PM. LPA observed care and supervision of 6 children supervised by the Licensee. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety evaluation was conducted in all areas accessible to children. Off limit areas consist of: all bedrooms, the garage and the shed. LPA observed a 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons in the home. No children were observed in parked cars. Toxic and hazardous items are inaccessible to children, and safe toys were observed. LPA reviewed 5 children’s files. Children’s files were observed to be complete. Required postings and the children’s roster were observed; LPAs advised Licensee to maintain the children’s roster for three years. Licensee does not have record of conducting fire drills at least every six months. LPAs reviewed staff files and observed files to be complete. LPA observed staff to be without masks; LPAs recommended COVID19 posters and current guidelines were discussed. LPA observed licensee’s CPR and First Aid card which expires 10/17/23 and Licensee has liability insurance on file. LPA discussed the requirement of renewing mandated reporter training every 2 years. Licensee’s Mandated Reporter Training is current and expires on 11/15/22. LPA provided a list of documents that are to be kept in the assistant’s file and reminded Licensee to ensure her assistants have current mandated reporter trainings. LPA informed Licensee that her fees are not current and has a balance of $210. Continued on LIC809C…

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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: STEPHENS, THEONIA	FACILITY NUMBER: 343621006
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2021

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 interview and record review, the licensee did not comply with the section cited above in fire drills have not been conducted or recorded which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof to LPA Tillery of having conducted a fire drill.

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: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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: STEPHENS, THEONIA	FACILITY NUMBER: 343621006
	VISIT DATE: 12/17/2021

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 submitting 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

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.

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.

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 [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.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Theonia Stephens.

A deficiency is cited on the following LIC809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

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