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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416146
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:19:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:COLEMAN, TAWNFACILITY NUMBER:
434416146
ADMINISTRATOR:TAWN COLEMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 420-1984
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:14CENSUS: 18DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Tawn ColemanTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Licensee Tawn Coleman and explained the reason for the inspection. Upon arrival, Licensee, her assistant, and 9 children were present, whom two were infant age. Licensee's assistant left to pick up children. At 2:03PM, LPA observed 10 school age children arrive, whom 3 were her own children. Two of whom are under 10 years old. Licensee's friend also arrived to help with the daycare children. Licensee stated that her friend is going to get fingerprinted. LPA discussed with Licensee about capacity and ratio and that anyone helping with the children need to be fingerprinted.

There is a board to post required postings. LPA also observed COVID posters posted. There is working phone in the home. The hours of operation are Monday through Friday 6:30AM to 5:30PM.

LPA toured the inside and outside of the home. The off-limit areas of the home are the entire upstairs, and the two bedrooms downstair. There is a fireplace and stairs in the home, which are barricaded. There is sufficient amount of toys for children. Furniture and equipment were observed to be good condition. There is a fully charged fire extinguisher, smoke detectors, and carbon monoxide detector. The last fire/disaster drill was conducted on 08/03/2021. Licensee stated there are no weapons, such as firearms, stored in the home. Licensee does have pets in the home.

The backyard is used and is fenced. All equipment were observed to be in good condition. LPA reminded Licensee to ensure any shed that have anything that could pose a risk to children are locked and any animal droppings are picked up.

-------------------continues on 809 dated 11/16/2021 page 2----------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: COLEMAN, TAWN
FACILITY NUMBER: 434416146
VISIT DATE: 11/16/2021
NARRATIVE
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----------------------continuation of 809 dated 11/16/2021 page 1---------------------------

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.

Licensee does transport children and does have a valid driver's license. Licensee also understands that children cannot be left alone and unattended in parked vehicles.



8 children's files were reviewed during today's inspection. LPA observed Licensee had immunization records on her phone was not able to pull it up. Licensee stated that she will send a copy of C-1's immunization to Licensing. did not have immunization records on file. LPA also observed that C-2 had the top portion of the LIC 282A but was not signed. Licensee does not have a facility rooster. Licensee stated that she will submit facility roster to Licensing.

Licensee and A-1's file were also reviewed. Licensee and her assistant have a valid CPR/1st Aid, which expires on 06/2023. They also have both completed the Mandated Reporter Training on 06/2021. LPA observed that A-1 did not have immunization record for measles and employee rights on file.



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SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: COLEMAN, TAWN
FACILITY NUMBER: 434416146
VISIT DATE: 11/16/2021
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----------------------continues on 809 dated 11/16/2021 page 2---------------------------------

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

Adults who are 18 and older and living in the home are Licensee, her father, and her adult daughter. All adults have cleared criminal records, child abuse index, and TB. 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.

As a result of this inspection, Type A citations have been cited. A civil penalty for $100 was issued for Criminal Record. Exit interview conducted and report was reviewed with Licensee Tawn Coleman. A notice of site visit was given and must remain posted for 30 days; along with a copy of this report.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 11/16/2021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Licensee that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Licensee.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COLEMAN, TAWN
FACILITY NUMBER: 434416146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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. Licensee's friend came to help with the daycare children, but was not fingerprinted. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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By POC 11/17/2021, Licensee stated that she was get her friend fingerprinted. Licensee understands that her friend cannot help until she is fingeprinted.
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee had 18 children present, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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By POC11/17/2021, Licensee stated that she submit a written plan outlining how she will ensure that she is within her capacity.
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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COLEMAN, TAWN
FACILITY NUMBER: 434416146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee was left alone with 9 children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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By POC 11/17/2021, Licensee stated she will submit a written plan on how she will ensure that she within ratio at all times.
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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9