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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480109049
Report Date: 12/16/2022
Date Signed: 12/16/2022 01:03:13 PM


Document Has Been Signed on 12/16/2022 01:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SPENCER FAMILY DAY CAREFACILITY NUMBER:
480109049
ADMINISTRATOR:SPENCER, JOYCEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 645-0514
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:14CENSUS: 2DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joyce Spencer - LicenseeTIME COMPLETED:
01:15 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 12/16/2022 indicates 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 four adults residing in the home. 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 the home and grounds were toured. The Licensee (LS) and one staff (S1) were supervising two child, the facility was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 6:00am - 6:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are four bedrooms, one bathroom and living/family room, and were made inaccessible by a child safety gate and door locking mechanism.

There is a working telephone in the home. There is a functional smoke detector and carbon monoxide detector; and a fully charged fire extinguisher rated at least 2A10BC. The Licensee stated the fireplace was not utilized during the facility’s operating hours. Licensee stated she did not store any poison(s) in the home, as well as LPA did not observe any. There were no firearm(s) or other dangerous weapons stored on the premise.

(Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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Document Has Been Signed on 12/16/2022 01:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SPENCER FAMILY DAY CARE

FACILITY NUMBER: 480109049

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on staff (LS & S1) records reviewed which revealed LS & S1's AB 1207 Mandated Reporter Training certificates were expired. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2023
Plan of Correction
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Licensee stated she, S1, and all staff would completed the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee would submit current certificates to the Department by 01/30/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing a current EMSA approved pediatric CPR/First Aid certification. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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Licensee stated she, S1, and all staff that pickup children alone would complete an EMSA approved pediatric CPR/First Aid training, and Licensee would submit copies of all staff;s current certificates to the Department via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2022 01:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SPENCER FAMILY DAY CARE

FACILITY NUMBER: 480109049

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on one child's (C1) record reviewed at 10:12am which revealed C1's Immunization Record was not transcribed onto the blue CDPH 286. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Licensee stated she would transcribed C1's Immunization Record onto the blue CDPH 286, and Licensee would submit the child's transcribed CDPH 286 to the Department by 12/30/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on one child's (C1) record reviewed at 10:12am which revealed the Affidavit Regarding Liability Insurance for FCCH (LIC 282) was not signed by C1’s parent/authorized representative. record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Licensee stated she would provide C1's parent with the LIC 282 and Licensee would submit a copy of the signed LICD 282 by 12/30/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPENCER FAMILY DAY CARE
FACILITY NUMBER: 480109049
VISIT DATE: 12/16/2022
NARRATIVE
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Licensee (LS) did not furnish a current AB 1207 Mandated Reporter Training certificates for LS and S1. Licensee did not furnish evidence of negative TB clearance for S1. LPA reviewed one child’s (C1) records at 10:12am which revealed C1’s Immunization Record (IR) was not transcribed onto the blue CDPH 286 form and the Affidavit Regarding Liability Insurance for FCCH (LIC 282) was not signed by C1’s parent/authorized representative.

During today’s inspection, Licensee stated there was/were zero infant(s) enrolled into care. According to the disaster drill log the Licensee provided to LPA, the facility had not conducted an emergency disaster drill within the past six months. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee did not furnish a current EMSA approved pediatric CPR/First Aid certification. The backyard appeared to be free of hazards and was fully fenced, and there were no pools or other bodies of water observed in the yard. LPA did not observe any baby walker(s), bouncer(s) and/or jumper(s).

The facility is providing Incidental Medical Services (IMS) to children in care. 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. LPA requested a Plan for Providing IMS from the Licensee. 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.

(Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPENCER FAMILY DAY CARE
FACILITY NUMBER: 480109049
VISIT DATE: 12/16/2022
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Licensee, Joyce Spencer. The following violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s inspection. Appeal Rights were provided.


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.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/16/2022 01:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SPENCER FAMILY DAY CARE

FACILITY NUMBER: 480109049

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)(1)
The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the facility's disaster drill log which indicated the Licensee had not conducted an emergency disaster drill, and Licensee did not provide evidence to prove a drill was conducted. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Licensee stated she would conduct an emergency disaster drill with the children in care, document the drill on the facility's disaster drill log, and submit a copy of the drill log and completed LIC 9098 to the Department via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff (LS & S1) records reviewed which revealed S1 did not have evidence of negative TB clearance. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Licensee stated she would ensure S1 obtained evidence of negative TB clearance and Licensee would submit evidence of S1's clearance to the Department via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7