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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483000103
Report Date: 11/19/2021
Date Signed: 11/19/2021 05:08:53 PM

Document Has Been Signed on 11/19/2021 05:08 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:WILLIAMS, CARMEN FAMILY CHILD CARE HOMEFACILITY NUMBER:
483000103
ADMINISTRATOR:WILLIAMS, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 642-0912
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Tina HegwoodTIME COMPLETED:
05:20 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 11/19/2021 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 is currently one adult living in the home.

During today’s inspection the home and grounds were toured. The facility representative (S1) was supervising eight children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 12:00AM to 11:59PM, Mon–Sun. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the upper level, office on the lower level and the garage, and were made inaccessible by door locking mechanism and children's safety gates. The home was clean and orderly and was at a comfortable indoor temperature. The fireplace in the family room was securely screened by a glass screen. There were safe toys and equipment available for children. There is a working telephone in the home. S1’s pediatric CPR and First Aid certification expire on 10/09/22. S1 furnished her AB 1207 Mandated Reporter Training certificate which expire on 03/11/2022. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The bottom of the staircase near the front entrance was barricaded with a child safety gate. There is a functional smoke and carbon monoxide detectors; and a fully charged 2A10BC fire extinguisher at the facility. The facility representative stated that poisons were not stored on site and LPA did not observe any poison during the inspection. Staff (S1-S3 & LS) records were reviewed at 12:00pm and records reviewed revealed that S2 was missing evidence of current TB clearance, as well as S1 did not furnish records for S3. During today’s inspection, there was one infant in care and S1 did not furnish evidence that 15 minutes checks had been conducted for napping infants. The facility conducted an emergency drill on 09/15/21. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103
VISIT DATE: 11/19/2021
NARRATIVE
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LPA reviewed children’s (C1-C9) record at 12:35pm, and records reviewed revealed C1, C4, C5, C7 and C9’s either had incomplete LIC 700 or were not singed or were missing LIC 627 or children’s immunization records had not been transcribed onto the blue CDPH 286. The facility representative stated there were no firearms and/or other dangerous weapons in the home. The backyard appeared to be free of hazards and was fully fenced. There were no pools or other bodies of water observed in the yard. The facility is not providing Incidental Medical Services (IMS) to children in care.

Facility representative 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.

LPA discussed the safe sleep regulations with S1 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.

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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. 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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/19/2021 05:08 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/19/2021 at 03:58 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records reviewed, the licensee did not comply with the section cited above. S2's record did not contain proof of immunity against the Measles, Pertussis and Infleunza, as well as S1 did not furnish record for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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S1 stated the will obtain their proof of immunity against the Measles, pertussis and Influenza and she will submit copies of staff required immunization records to the Department by 12/10/21.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
Section Cited
HSC
1596.8662(b)(1)
On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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 records reviewed, the licensee did not comply with the section cited above. S1 did not furnish AB 1207 Mandated Reporter Training certificate for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/25/2021
Plan of Correction
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S1 stated she will submit AB 1207 Mandated Reporter Training certificate for S3 by 12/25/21. Staff may complete the online training module at mandatedreporterca.com.

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 Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/19/2021 05:08 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/19/2021 at 04:13 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above. LPA reviewed staff records at 12:00pm and records reviewed recvealed S2 was missing evidence of current TB clearance, as well as S1 did not furnish records for S3. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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S1 stated S2 and S3 would obtain proof of negative TB clearnance and submit evidence of TB clearance to the Department by 12/10/21 via mail. email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
Section Cited
CCR
102370(c)
All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed at 12:00pm, the licensee did not comply with the section cited above. During today's inspection, S1 did not furnish record for S3 or a copy of completed LIC 508 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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S1 stated she would submit completed LIC 508 for S3 and submit a copy of the completed LIC 508 to the Department by 12/10/21 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 Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/19/2021 05:08 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/19/2021 at 04:15 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. During today's inspection, the facility representative did not furnish record for S1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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S1 stated the facility would produce a file and records for S3 and would submit required records for S3 to the Department by 12/10/21 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
Section Cited
CCR
102417(7)
An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on children's records reviewed, the licensee did not comply with the section cited above. Children's records reviewed revealed that C4, C5, C7, C8 and C9's either did not have a signed LIC 700 or the form was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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S11 stated she would complete and/or obtain parental signature(s) on the LIC 700 and she would submit the completed and signed forms to the Department for C4, C5, C7, C8 and C9. The POC would be submitted 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 Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/19/2021 05:08 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/19/2021 at 04:21 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel records shall be maintained on each employee and shall contain the following information: A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above. During today's inspection, S1 did not furnish a signed copy of the employee rights for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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2
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S1 stated she would submit a singed copy of the employee rights for S3 to the Department by 12/10/21 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
Section Cited
CCR
102418(h)(1)
California Code of Regulations, Title 17, Section 6070, specifies in pertinent part that:
The family day care home shall record each pupil's immunization on the California School Immunization Record, PM 286 (6/95).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on children's records reviewed, the licensee did not comply with the section cited above. Children's records reviewed revealed that C1 ad C5's immunization was not transcribed onto the CDPH 286. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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2
3
4
S1 stated the facility would obtain parental signature on LIC 627 for C1 and C5, and would submit copies of the LIC 627 with parental signature to the Department by 12/10/21 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 Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/19/2021 05:08 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/19/2021 at 04:54 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with the facility representative, the licensee did not comply with the section cited above. S1 did not furnish proof that 15 minutes checks were being conducted during infant's nap time, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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2
3
4
S1 stated she would produce a written statement detailing how the facility intends to conduct 15 minute checks and how the facility intends to comply with ccr 102425(j)(1), and will also complete lic 9098 to the Department by 12/10/21. LPA also provided S1 with a copy of a RO produced infant Sleep Log. The POC will be submitted to the Department by 12/10/21 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


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