483001308-8-11-2022-01-CC-MAUN-CH7RA9-20220811125046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483001308
Report Date: 08/11/2022
Date Signed: 08/11/2022 12:52:20 PM

Document Has Been Signed on 08/11/2022 12:52 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:	GRAVES, MARIA FAMILY CHILD CARE HOME		FACILITY NUMBER:	483001308
ADMINISTRATOR:	GRAVES, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 557-7473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	12	CENSUS: 4	DATE:	08/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Maria Graves - Licensee		TIME COMPLETED:	01:00 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	A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 08/11/2022 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 three adults living 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. During the visit, the Licensee (LS) was supervising four children (C1-C4) and 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 5:30am - 6:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are one bedroom, one bathroom, garage and the lower level of the home, and were made inaccessible by door latch and a door locking mechanism. The staircase in the hallway was barricaded by a latched door. There is a working telephone in the home. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. LPA did not observe any poison(s). There were no firearm(s) or other dangerous weapons stored on site. The children’s outdoor play area is on a wooden outdoor patio deck which had several loose posts that required fortification. Licensee furnished a current AB 1207 Mandated Reporter Training certificate and required Immunization Record. LPA requested to review four children's (C1-C4) records at 10:04am, however; the Licensee only furnished records for C1-C3. C1's record was missing Immunization Record (IR), transcribed CDPH 286 & LIC 9227, while C2 & C3 records were missing IR and transcribed CDPH 286. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
	VISIT DATE: 08/11/2022

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
26
27
28
29
30
31
32

During today's inspection, LPA observed the Licensee was supervising two children on the main floor while an infant under 12 months old was napping in a play yard in a bedroom that was one floor beneath the main floor. The Licensee did not furnish evidence to prove that 15 minutes checks had/was being conducted for C1 & C4. LPA observed two children under 24 months old enrolled in care and there were three play yards available. The facility did not conduct 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's did not furnish a current EMSA approved pediatric CPR/First Aid certification. 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. 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 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.

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. The following violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s visit. Appeal Rights were provided.

(Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 2 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
	VISIT DATE: 08/11/2022

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
26
27
28
29
30
31
32

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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 08/11/2022 12:52 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of the children’s outdoor play area which is on a wooden patio deck that had several loose screws & posts that required fortification. 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would fortify the outdoor wooden patio deck posts and a follow up inspection is required by LPA to verify repair. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the Licensee's statement and review of disaster drill log which indicated that the Licensee did not conduct an emergency disaster drill within the past six months. 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would condcut an emergency disaster drill, document the drill and submit evidence to prove that an emergency disaster drill had been conducted. LPA also provided a copy of the LIC 9098 to be submitted with the disaster drill log. 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	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 08/11/2022 12:52 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(1)

Infant Safe Sleep

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 the Licensee not furnishing evidence to show 15 minute checks had/was conducted for C1 & C4. 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would document three days worth on the Sleep Log to prove that 15 minutes checks were being conducted for C1 & C4. The Licensee stated she would submit the Sleep Log to the Department by 08/25/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Type B

Section Cited

CCR

102425(j)(6)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall be on the same floor as the sleeping infant. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of a child under 12 months old napping in a play yard in a bedroom that was on a separate floor than the Licensee. 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would produce a written statement to indicate she intends to have the child nap in a play yard on the same floor as the provider. The Licensee stated she would submit her POC to the Department via mail, email or fax by 08/11/22. 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	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 08/11/2022 12:52 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on LPA's review on the Licensee's pediatric CPR/First Aid certification which revealed the certification was expired. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2022
	Plan of Correction
1 2 3 4	Licensee stated she would regsiter for an EMSA approved pediatric CPR/First Aid training and the Licensee would complete and submit a copy of her current certification to the Department by 09/08/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Type B

Section Cited

CCR

102418(g)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's review of three children's (C1-C3) records at 10:04am which revealed all the children's records did not contain Immunization Records and transcribed 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would request Immunization Records from the children's parents and submit evidence to prove C1-C4 were immunized prior to entry into care. 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	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 08/11/2022 12:52 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: GRAVES, MARIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001308
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the Licensee not furnishing a record for C4 upon LPA's request to 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: 08/18/2022
	Plan of Correction
1 2 3 4	Licensee stated she would provide and submit children's record which consisted of licensing forms 282, 627, 700, 995, current Immunization Record, and transcribed CDPH 286. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on children's (C1-C3) records reviewed at 10:04am which revealed C1's record was missing LIC 9227. 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: 08/25/2022
	Plan of Correction
1 2 3 4	Licensee stated she would provide C1's parent with LIC 9227 and obtain the completed form, and submit the completed form to the Department by 08/25/22 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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 7 of 7