376623793-4-22-2022-20-CC-DMIR-CDQP6Q-20220422110242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376623793
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:02:56 AM

Document Has Been Signed on 04/22/2022 11:02 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	RAVEN, TIFFANIE FAMILY CHILD CARE		FACILITY NUMBER:	376623793
ADMINISTRATOR:	TIFFANIE RAVEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 307-1975
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	14	CENSUS:	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	11:15 AM

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 April 22, 2022 at 9:15, Licensing Program Analyst (LPA) David Miller conducted an unannounced Annual Required Inspection and met with the Licensee Tiffanie Raven. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. The licensee and three (3) daycare children (ages 1-3) were present in the facility during this inspection. This facility is a one story, four (4) bedroom, two (2) bathroom apartment. Licensee accompanied LPA during this inspection. Licensee is using the following areas for daycare: Play room, dining room, kitchen, family room, bathroom 1. Off limits areas include: bedrooms 1, 2, 3 and 4, master bathroom, and the garage. Applicant states she will utilize backyard for outdoor activities. Licensee was reminded that she may not make any changes to approved daycare areas before consulting with the licensing office. The fire extinguisher and smoke/carbon monoxide detector met requirements. Hazardous items were observed inaccessible to children during this inspection. The licensee has available toys, play equipment and materials. Children play outside in the fenced frontyard. Licensee was reminded that continuous supervision is to be given to children whenever engaged in outdoor activities. No bodies of water were observed on the premises during the inspection. Licensee stated there are no weapons in the home and LPA did not observe any firearms at the time of this inspection. Licensee’s First Aid and CPR certifications expire in 04/24/2024. Licensee has required immunizations. Licensee completed the mandated reporter training on 03/03/2022. The facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 03/03/2022.

SUPERVISOR'S NAME: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RAVEN, TIFFANIE FAMILY CHILD CARE	FACILITY NUMBER: 376623793
	VISIT DATE: 04/22/2022

NARRATIVE

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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 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 reminded Licensee of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.

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 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.

SUPERVISOR'S NAME: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RAVEN, TIFFANIE FAMILY CHILD CARE	FACILITY NUMBER: 376623793
	VISIT DATE: 04/22/2022

NARRATIVE

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The following was cited: Type B: 102425(j)(2)(D) was issued due to the licensee stating that she did not have an individual sleeping plan for infants under 12 months and also was not documenting in a sleep log that she was checking on sleeping children under two every 15 minutes.

A copy of the report and appeal rights (LIC 9058) was provided to the applicant and notice of site visit (LIC9213) was given to Licensee and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Licensee Tiffanie Raven. 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: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 11:02 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RAVEN, TIFFANIE FAMILY CHILD CARE	FACILITY NUMBER: 376623793
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews and record review the licensee did not comply with the section cited above. There was no sleep log for 1 child while child was 12 months and under, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will maintain an individual sleep plan for infants 12-months and younger

Section Cited

Infant Safe Sleep


	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: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 11:02 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RAVEN, TIFFANIE FAMILY CHILD CARE	FACILITY NUMBER: 376623793
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(a)

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: Date. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview and record review the licensee did not comply with the section cited above. Documentation of the sleep plan and sleep log were not ket, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will maintain a sleep log

Section Cited

Infant Safe Sleep


	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: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 04/22/2022 11:02 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RAVEN, TIFFANIE FAMILY CHILD CARE	FACILITY NUMBER: 376623793
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

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: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above. A 15-minute check slee log was missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee stated that she will maintain and document a sleep log that highlights monitoring and recording every 15 minutes

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: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: David Miller	TELEPHONE: (619) 987-8901
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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