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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475406362
Report Date: 06/12/2019
Date Signed: 06/13/2019 08:57:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:ROTH, PEGGY FAMILY CHILD CARE HOMEFACILITY NUMBER:
475406362
ADMINISTRATOR:ROTH, PEGGYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 842-3582
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:14CENSUS: 10DATE:
06/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Peggy RothTIME COMPLETED:
02:45 PM
NARRATIVE
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A Annual inspection was made to the facility by Licensing Program Analyst (LPA), Snow who met with Licensee, Peggy Roth. A review of staff records on 6/12/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently 2 adults living in the home.
During today’s inspection the home and grounds were toured. The licensee was supervising 10 children without and assistant. The LPA observed an infant was observed in a car seat for 18 minutes at 10:28am and again at 2:06pm. No children were observed left in any parked vehicle. The facility’s operating hours are 8:30am to 7:00pm Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are everything in the home except for the kitchen & attached living room and a bathroom. The children require an escort through the entryway and gate into the child care area. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 3/16/21. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Poisons are key locked in the garage. The fireplace has been made inaccessible with gate attached to the wall. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: ROTH, PEGGY FAMILY CHILD CARE HOME
FACILITY NUMBER: 475406362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2019
Section Cited
CCR
102416.5(b)
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Staffing Ratio and Capacity: Up to eight children, without an additional adult attendant. As evidenced by the Licensee caring for Ten children without an assistant observed from
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Assistant arrived after 10:57am
The Licensee agrees to only care for the maximum children allowed at one time and that the assistant must be present with the children to supervise.
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10:47 AM to 10:57AM. (One infant and one school age child) Insert this statement: which poses an immediate Health and Safety risk to children in care.
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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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ROTH, PEGGY FAMILY CHILD CARE HOME
FACILITY NUMBER: 475406362
VISIT DATE: 06/12/2019
NARRATIVE
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The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the front yard for outdoor play area and it is fully fenced. There were no pools or other bodies of water observed.
Five children's records were reviewed starting at 10:20am and the required emergency information was observed to be on file. Some of the other children’s files were missing items or missing completely. The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.
* Printer malfunction during the visit, the LPA will email report on 6/13/19
* The LPA was not present at the facility 11:30am-2:00pm.

Notice of Site Visit shall be posted for 30 days from today's visit.

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: ROTH, PEGGY FAMILY CHILD CARE HOME
FACILITY NUMBER: 475406362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2019
Section Cited
CCR
102417(d)
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Operation of a Family Child Care Home: The home shall provide safe toys, play equipment and materials.
As evidenced by the infant child #6 in a car seat from 10:10AM until 10:18AM which poses/posed a potential Health and Safety risk to children in care.
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The Licensee agrees to no longer use the car seat during day-care hours.
Type B
07/12/2019
Section Cited
CCR
102421
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Child's Records: Licensee shall document and maintain each child’s record.
As evadenced by Licensee unable to locate records for child #5 and #6.
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The licensee agreed to obtain full records for all attending children and submit a statement to Community Care Licensing as proof of correction by 7/12/2019.
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 The licensee said there is no file for child #9 and # 10. Immunization records were missing for child #A, B, C & D which poses a potential Health and Safety risk to children in care.
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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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
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