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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374845478
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:57:35 PM


Document Has Been Signed on 06/07/2022 12:57 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:ADAMS FAMILY CHILD CAREFACILITY NUMBER:
374845478
ADMINISTRATOR:JACQUELYN ADAMSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(425) 512-6236
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:14CENSUS: 9DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Jacquelyn AdamsTIME COMPLETED:
01:05 PM
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On date and time listed, Licensing Program Analyst (LPA) Jessica Rubio arrived at the facility to conduct an annual inspection as part of a compliance review. LPA met with licensee Jacquelyn Adams. 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: Monday through Friday 7:00 am – 5:30 pm.

· Off-limit areas include: 3 bedrooms, one bathroom, the garage and the side yard areas.

· The facility is operating within the licensed capacity and appropriate ratios


· Appropriate supervision was provided during this inspection

· A working telephone is present and the current number is on file

· Appropriate fire extinguisher was located in the hallway, smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.

· A fireplace is properly screened to prevent access by children

· All hazardous items were not stored inaccessible to children. LPA observed scissors, sharp knives (some with covers) and lighters in a kitchen drawer with a child safety latch that was no longer working properly. LPA advised licensee to replace the safety latches and make the items inaccessible. Licensee immediately removed the items and placed them high in the kitchen pantry that has a child proof door knob. It should be noted that children were not present in the location and mainly use the area as a walk through area and appropriate supervision was also being provided by two other assistants.

· Toxins are locked (Continued on LIC 809-C)

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 374845478
VISIT DATE: 06/07/2022
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· Weapons are not present in the home. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Clean, safe and age appropriate toys were observed

· Current roster is 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 03/09/2022

· 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 is on file

· Ten children’s records were reviewed. Nine out of ten records were complete. One child (C10)’s records were incomplete as they did not contain an LIC 9227 or documentation of 15 minute sleep checks. LPA provided technical assistance and technical violations are being issued.

· Four staff files and one adult resident file was reviewed. All staff records are complete and all employees have the required background checks and have received clearances and/or exemptions. The adult resident (A1) file was incomplete as A1 had not completed a Child Abuse Central Index check. A Type B citation will be issued.

· Licensees Mandated Reporter Training expires on 4/6/2023

· Pediatric CPR and First Aid Card expire on 1/2/2023

· Health & Safety Certificate - completed on 1/27/2019. Lead component completed on 7/15/2020.



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: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 374845478
VISIT DATE: 06/07/2022
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 [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.

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.

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.

The facility is being cited for Title 22 Regulation Section 102370.2 (b). See LIC809-D for cited deficiencies.
An exit interview was conducted, and this report was reviewed with the licensee Jacqueline Adams. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and must remain posted for 30 days. (Continued on LIC 809-C)
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: ADAMS FAMILY CHILD CARE
FACILITY NUMBER: 374845478
VISIT DATE: 06/07/2022
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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.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 06/07/2022 12:57 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: ADAMS FAMILY CHILD CARE

FACILITY NUMBER: 374845478

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370.2(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as adult resident (A1) did not complete a Child Abuse Central Index (CACI) check which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2022
Plan of Correction
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Licensee agreed to have A1 re-fingerprinted to include the CACI check and provide proof to LPA by plan of correction due date.
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: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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