426205523-3-14-2022-17-CC-GRES-CCHV6U-20220314161006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 03/14/2022
Date Signed: 03/14/2022 04:10:13 PM

Document Has Been Signed on 03/14/2022 04:10 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	BORNEMAN FAMILY CHILD CARE		FACILITY NUMBER:	426205523
ADMINISTRATOR:	TRACEY ANN BORNEMAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 264-8444
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	14	CENSUS: 9	DATE:	03/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Tracey Ann Boreman		TIME COMPLETED:	04:15 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 March 14, 2022 at 2:00PM , Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced 1 Year Required Inspection. LPA asked Covid-19 screening questions prior to the inspection. LPA met with Licensee Tracey Borneman and discussed the purpose of the inspection. Licensee provided LPA a tour of the facility inside and out. There were 9 children and 3 staff present during the inspection including the Licensee. During the tour LPA observed the following, required forms are posted in the prominent location. Appropriate fire extinguisher was serviced on 5/2/2021. At 2:30 PM Smoke and carbon monoxide detectors were tested and found functional. Toxins and detergent are locked inaccessible to children in care. The backyard is completely fenced. LPA observed age appropriate toys and equipment in the outside play area. Nobodies of water was observed. Licensee stated there are no guns or ammunition in the home. LPA reviewed the following documents, Pediatric CPR and First Aid Card expires 7/10/2023. Licensee's Mandated Reporter Training Certificate expired on 1/20/2022. The staff immunization record is complete per SB 792. Fire and Disaster drill is conducted and logged every month . Last drill was conducted on 2/14/2022. Children’s roster is current. LPA reviewed children records. Licensee physically checks and documents napping infants every 15 minutes. LPA observed that LIC 9227 Infant are filled out and signed. Continued on 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: BORNEMAN FAMILY CHILD CARE	FACILITY NUMBER: 426205523
	VISIT DATE: 03/14/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home 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.

LPA discussed current Safe Sleep and Covid-19 requirements with Licensee.
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.

During today's inspection deficiency cited under California Code of Regulation Title 22 Division 12. Deficiency was documented under LIC 809 D.

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

Exit interview conducted and report was reviewed with the Licensee, Tracey Borne

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2022 04:10 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: BORNEMAN FAMILY CHILD CARE	FACILITY NUMBER: 426205523
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 LPA review, , the licensee did not comply with the section cited above Licensee and Assistant's Mandated Reporter Training Certificates expired on 1/20/22/ and 3/9/2022 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2022
	Plan of Correction
1 2 3 4	Licensee and assistant agreed to renew Mandated Reprioter Training per AB 1207 and submit the certificate and plan of correction no later thatn 3/23/2022.

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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