393622804-3-1-2023-53-CC-ESIA-CPHSSH-20230301130759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393622804
Report Date: 03/01/2023
Date Signed: 03/01/2023 01:08:07 PM

Document Has Been Signed on 03/01/2023 01:08 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	STOREY, MONICA		FACILITY NUMBER:	393622804
ADMINISTRATOR:	GUARDADO, MONICA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 227-8323
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 10	CENSUS: 7	DATE:	03/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Monica Storey		TIME COMPLETED:	01:10 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 03/01/23, Licensing Program Analyst (LPA) Elvira Sierra met with the Licensee, Monica Storey for the purpose of an unannounced annual inspection. Facility hours of operation are M-F from 06:00am to 06:00pm. A review of the Facility Personnel Summary shows that all adults living and working in the home have criminal record clearances on file with Licensing Office. Licensee stated that no new adult residents moved into the home since licensure. Present in the facility was Licensee and assistant caring for 7 children.

A health and safety inspection was conducted in all areas accessible to children. Off limit areas are: Bedroom #3, #4, #5 and #6, Living Room, Family Room, Bathroom # 2, Left and Right side of the backyard including the storage unit in the backyard. Licensee was reminded that day care children may never enter these off-limit areas. LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights by the main entrance of the home. LPA observed the home was clean and appropriately ventilated. Facility maintains a working phone, 2A10BC fire extinguisher, and functioning smoke/carbon monoxide detector. Licensee stated there are no weapons in the home. No bodies of water were observed on the premises. Toxic and hazardous items are inaccessible to children. Medications are kept off limit to the children. The fireplace in the home is appropriately barricaded to prevent access by children. Outdoor play area is free of any hazards. Licensee CPR expires on 04/09/24 Mandated Reporter training certificate was observed and expires on 03/12/24. LPA provided PIN 20-24 Recently approved safe sleep regulations in effect, Safe Sleep Regulation Concept.

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.

Report continues on subsequent page 809C-

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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: STOREY, MONICA	FACILITY NUMBER: 393622804
	VISIT DATE: 03/01/2023

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
26
27
28
29
30
31
32

LPA discussed the safe sleep regulations 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. LPAs 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.

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

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

Deficiencies were cited on subsequent page 809D. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC 809 D 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. 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. Exit interview was conducted. LIC 9224 and Appeal Rights were reviewed and provided to Licensee, Monica Storey.

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

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/01/2023 01:08 PM - It Cannot Be Edited

Created By: Elvira Sierra On 03/01/2023 at 12:25 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: STOREY, MONICA	FACILITY NUMBER: 393622804
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. 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 by having a sleeping baby in a play yard with a blanket and loose fitted sheet attached to the play yard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/02/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will obtaint a crib/playpen for infants that need a crib by POC due date..

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:

Bettina Engelman

LICENSING EVALUATOR NAME:

Elvira Sierra

LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3