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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623343
Report Date: 09/27/2021
Date Signed: 09/27/2021 01:21:38 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:KING, CONNIEFACILITY NUMBER:
343623343
ADMINISTRATOR:KING, CONNIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 752-9904
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:14CENSUS: 2DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Connie KingTIME COMPLETED:
01:35 PM
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On Monday, 09/27/21, at 10:30am, Licensing Program Analyst (LPA) Jan Hoshida conducted an unannounced random annual inspection and met with Licensee Connie King. Upon arrival, LPA observed there were two day care children present in the facility during this inspection. The off-limit areas include the entire upstairs and garage. Licensee acknowledged that children may never enter these off-limit areas. Licensee stated there are no new residents in the home since licensure. All adult residents have criminal record clearances. The hours of operation are from 6:00am to 8:00pm (seven days a week).

LPA observed current CPR/First Aid certificates which expire on 06/2023. LPA observed current Mandated Reporter Training in file and was taken on 06/09/21. LPA reviewed some children’s files. LPA observed fire drills were conducted at least once every six months and documented. LPA observed that there were no hazardous items accessible to children. LPA observed fireplace which was screened. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe. The backyard is fenced and gated. LPA observed that there is a play structure in the back yard and there is grass and wood chips on the bottom and around the structure. Licensee stated that there are no weapons in the home. LPA discussed current COVID guidelines with Licensee.

LPA observed that there was not a gate at the bottom of the stairs that lead to the second floor. Licensee stated that the gate fell off and she will make sure that it is re-installed correctly. Licensee stated that she has been immunized against pertussis and measles, but she does not have record of it within her home. Licensee stated that she did not know that was a requirement and will obtain those documents for her and her assistant/son and provide proof to LPA.

REPORT CONTINUED ON NEXT PAGE
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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 3
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: KING, CONNIE
FACILITY NUMBER: 343623343
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee stated that the gate fell off and she will make sure that it is re-installed correctly. Licensee will submit proof of a barricade on the bottom of the stairs that lead to the second floor to LPA by POC due date of 10/27/21.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee stated that she has been immunized against pertussis and measles, but she does not have record of it within her home. Licensee stated that she did not know that was a requirement and will obtain those documents for her and her assistant/son and provide proof to LPA by POC due date of 10/27/21.
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 LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KING, CONNIE
FACILITY NUMBER: 343623343
VISIT DATE: 09/27/2021
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This facility does not currently provide Incidental Medical Services- IMS. 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.

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 provided Licensee the Safe Sleep PIN 20-24 CCP and Infant Individual Sleeping Plan (LIC 9227). Licensee stated that she does not currently have any children under that age of two years. 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.



LPA checked facilities fees and confirmed that it is up to date.

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.

In the areas that were evaluated, deficiencies were observed at the time of the visit and cited on LIC 809-D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Connie King.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan HoshidaTELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3