364819798-3-30-2023-09-CC-SBRR-CQF3LP-20230330182105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364819798
Report Date: 03/30/2023
Date Signed: 03/30/2023 06:21:51 PM

Document Has Been Signed on 03/30/2023 06:21 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	INGRAM FAMILY CHILD CARE		FACILITY NUMBER:	364819798
ADMINISTRATOR:	INGRAM, NICOLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 422-9938
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	14	CENSUS: 15	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Licensee Nicole Ingram		TIME COMPLETED:	06:35 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 03/30/2023 at 1:25 PM Licensing Program Analysts (LPAs) Susan Brewer and Perla Ordones arrived at the facility to conduct an annual inspection. LPAs were greeted by Staff 1 (S1) Donae Smith and granted entry to tour the facility inside and out. Per S1, the licensee Nicole Ingram, was away from the daycare. S1 and LPAs, reached out to the Licensee N. Ingram, by phone to notify that the inspection was taking place. Present were two staff, 3 minor residents. LPAs reviewed records and observed and/or discussed the following: LPAs requested updated changes on forms LIC279 Application form, LIC279B Resident Children, LIC610A Emergency Disaster Plan. Normal days and hours of operation are: Monday through Friday, 5:30 AM to 6:00 PM OFF-LIMIT AREAS INCLUDE: All bedrooms and the garage. The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D. · The facility is NOT operating within the licensed capacity and appropriate ratios. At 1:27 PM, LPAs took a census of 15 children present and in care. · The Licensee was not present in the home and has ensured that children in care are supervised. · When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children. · A working telephone is present. · LPA observed a fire extinguisher to be the 1A:10-B:C and not the required 2A:10BC, smoke detector and carbon monoxide detector are present, were tested by S1, during this inspection and working.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
	VISIT DATE: 03/30/2023

NARRATIVE

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· All hazardous items are NOT inaccessible, this includes detergents, cleaning compounds, medications and other items which could pose a danger to children. LPA Perla Ordones, observed dish detergent and Mr. Clean scrub pads, under the kitchen sink, without a latch. The products were removed by S1 and placed in the garage in the presence of the LPAs.
· Storage of poisons is inaccessible to children and locked on 03/30/2023.
· There is a properly barricaded fireplace on 03/30/2023.
· No guns or weapons present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
· No stairs, this is a 1 level home.
· Home is clean and orderly, with heating and ventilation for safety and comfort.
· Clean, Safe and age appropriate toys and equipment are present for both indoor and outdoor activities.
· Outdoor play areas are fenced and/ or appropriate supervision is present. Per S1, the outdoor play area is temporarily off-limits and the children do not have access at this time. The licensee plans to upgrade the turf.
· Verification of control of property on file.
· Property owner/landlord notification and consent dated 11/13/2007
· Pediatric CPR and First Aid Card expires on 07/2023 for S1.
· Health & Safety Certificate - completed on 11/04/2007
· Mandated reporter General: NOT ON FILE; AB 1207 Child Care Expires: NOT ON FILE
· Fire clearance: 12/03/2007
· Documentation of fire & earthquake drills to be conducted every six months: Last drill on 12/08/2022.
· There are no bodies of water on 03/30/2023. Licensee and Staff 1, 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.
· Children’s files are NOT complete for children present and in care: 3 children did not have records on file or LIC700 Emergency Identification forms, 1 child missing signatures on the LIC700 Emergency Identification form, 6 missing immunizations, 3 missing LIC995 parent rights, 5 not listed on the facility roster, 4 missing LIC627 consent for medical treatment; 3 missing the lic282, 3 missing proof enrollment in school; Infant Children present did not have sleep logs, 1 infant present under 12 months old did not have LIC9227 form.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
	VISIT DATE: 03/30/2023

NARRATIVE

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· Staff’s files are NOT complete: A staff member present and caring for children did not complete the required criminal background clearance, both staff members present failed to complete the CA Child Abuse Mandated Reporter Training Part 1 and 2; 1 staff present did not have proof of Measles or Influenza, 1 staff present was missing Tdap, Measles and Influenza.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
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 Staff 1 Donae Smith, 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. The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov for Riverside Regional Office.

LPAs Susan Brewer and Perla Ordones, discussed the safe sleep regulations with licensee Nicole Ingram, 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.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
	VISIT DATE: 03/30/2023

NARRATIVE

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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.

See LIC809D for cited deficiencies this visit 03/30/2023.
Civil Penalties Issued on 03/30/2023

Appeal rights discussed and a copy of this report was provided to the licensee on this date.

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.

LPAs Susan Brewer and Perla Ordones, informed facility representative Donae Smith, that this report dated 03/30/2023 documents 2 of Type A citation. Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

Also, LPAs Susan Brewer and Perla Ordones, informed facility representative Donae Smith to provide a copy of this licensing report dated 03/30/2023 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee representative Donae Smith, on behalf of the Licensee Nicole Ingram.

SUPERVISOR'S NAME: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2023 06:21 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

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
1 2 3 4	Based on observation and record review, and Guardian check for associations, the licensee Nicole Ingram did not comply with the section cited above in a staff present Elizabeth Cuevas Lopez, did not complete their criminal background clearance and is supervising children on 03/30/2023, which poses an immediate health, safety or personal rights risk to persons in care. Per Elizabeth Cuevas Lopez, they began working at the facility in August of 2021.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain a criminal background clearance for all employees, prior to working with children at the facility and provide proof of employee Elizabeth Cuevas Lopez, prior to returning to the facility. The licensee agrees to write a statement of understanding the regulation for Criminal Record clearances and submit to the department on or before 03/31/2023.

Type A

Section Cited

CCR

102416.5(d)

Staffing Ratio and Capacity

(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above, where LPAs coducted a census 1:27 PM of 15 children present and in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	LPAs observed parents picking up children at approximately 3:30 PM. The licensee agrees to write a written statement of understanding the staffing ratio and capacity for a large family child care home with a qualified assistant present and submit to the department on or before 03/31/2023. All children exitied the facility by 05:45PM.

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: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.543

Licensure Requirements

Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in observed a fire extinguisher to be the 1A:10-B:C and not the required 2A:10BC, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	The licensee agrees to provide proof of a the required 2A:10BC, puchased and stored at the facility on or before 04/14/2023, by fax, mail or e-mail.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 staff present and caring for children did not have Mandated Reporter Training Certificates Part 1 and 2; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	The licensee agrees to provide proof of CA Child Abuse Mandated Reporter Training Certificates Part 1 and 2, for the licensee and staff working with children on or before 04/28/2023.

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: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(a)

Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 2 staff present and working with children did not have a personnel file when requested by LPAs, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that personnel files are available for review for all staff and volunteers employed to work with children and provide proof of personnel documents on or before 04/14/2023.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Staff present and working with chidlren were missing proof of MMR, Influenza and Tdap, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that personnel have proof of immunizations available for review for all staff and volunteers employed to work with chidlren and provide proof of immunization documents on or before 04/14/2023.

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: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review on 03/30/2023, the licensee did not comply with the section cited above in which 6 children were missing immunization records, 3 children did not have files, 3 children had statements that they did not want immunizations due to religious reasons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain immunization records for all children enrolled and attending daycare and provide proof of immunizations to the department on or before 04/14/2023.

Type B

Section Cited

CCR

102419(d)

Admission Procedures and Parental and Authorized Representative's Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above 3 children were missing files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	The licensee agrees to obtain immunization records for all children enrolled and attending daycare and provide proof of the LIC995A Parents Rights, to the department on or before 04/14/2023

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: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2023 06:21 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE	FACILITY NUMBER: 364819798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(d)(1)

Infant Safe Sleep

The provider shall place infants up to 12 months of age on their backs for sleeping. This requirement shall not apply if the infant has a medical exemption from a licensed physician that allows for an alternative sleep position. The exemption shall be attached to the Individual Infant Sleeping Plan [LIC 9227 (3/20)] and contain the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 infant child in care under 12 months old did not have a LIC9227 Individual Infant Sleeping Plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2023
	Plan of Correction
1 2 3 4	The licensee agrees to provide proof of a LIC9227 Individual Infant Sleeping Plan on or before 04/03/2023.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 infants under 24 months, did not have infant sleep logs, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2023
	Plan of Correction
1 2 3 4	The licensee agrees to provide proof of a Infant Sleeping Log on or before 04/07/2023.

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: Kimberly Williams	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Susan Brewer	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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