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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393616379
Report Date: 07/10/2019
Date Signed: 07/10/2019 11:22:34 AM

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:GRAHAM, CYNTHIA MFACILITY NUMBER:
393616379
ADMINISTRATOR:GRAHAM, CYNTHIA MFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 836-0282
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 11DATE:
07/10/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cynthia GrahamTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Ponce met with licensee for a Case Management- Deficiency Inspection. During a separate inspection, LPA Ponce toured the bathroom used by children in care and observed razors and shaving cream which is am immediate health and safety risk. Licensee's husband immediately removed the razors and shaving cream from the bathroom which clears this deficiency. LPA Ponce advised licensee to ensure that there are no dangerous items within reach of children in care.

Title 22 deficiencies are cited on the subsequent pages of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee (LIC 9224 was provided).

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
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: GRAHAM, CYNTHIA M
FACILITY NUMBER: 393616379
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home.Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be
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POC: Licensee's husband cleared the bathroom of razors and shaving cream. LPA advised licensee to ensure that there are no items that pose immediate health and safety risk in an area
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stored where they are inaccessible to children. This regulation was not met as evidence by razors and shaving cream being accessible to children in care.
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accessible to children.
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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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
LIC809 (FAS) - (06/04)
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