483001979-3-29-2023-01-CC-MAUN-CQDRHC-20230329130203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483001979
Report Date: 03/29/2023
Date Signed: 03/29/2023 01:02:14 PM

Document Has Been Signed on 03/29/2023 01:02 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:	SIMMONS, NINA FAMILY CHILD CARE HOME		FACILITY NUMBER:	483001979
ADMINISTRATOR:	SIMMONS, NINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 557-1102
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	14	CENSUS: 5	DATE:	03/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Nina Simmons - Licensee		TIME COMPLETED:	01:15 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 03/29/2023 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. 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. There are currently two adults living in the home. During today’s inspection the home and grounds were toured. There were five children in care with Licensee (LS) and three staff (S1, S2 & S3), 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 8:30AM to 12:00AM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire upper level of the home and the garage and were made inaccessible by a child safety gate and plastic doorknob covers. The interior of the home was clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s EMSA approved pediatric CPR/First Aid certification expire 11/13/2023. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. The Licensee stated she did not store any poison(s), or firearm(s) or other dangerous weapon(s) on site; and none were observed by LPA. Licensee furnished a current copy of her AB 1207 Mandated Reporter Training certificate, as well as current copies for S1 & S2. (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: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SIMMONS, NINA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001979
	VISIT DATE: 03/29/2023

NARRATIVE

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During today’s visit, there were zero enrollees under the age 24 months old present. LPA reviewed four children’s (C2-C5) records at 9:59am, which revealed C2-C5’s record contained all required licensing forms. LPA reviewed two staff records at 10:12am and later reviewed a third staff (S3) record. S1 & S2's records contained AB 1207 Mandated Reporter Training certificates and required Immunization Records, however; S3 was missing evidence of negative TB clearance. The facility conducted an emergency drill and documented the drill on 03/29/23. The facility roster of the children in care was reviewed and appeared to be complete. There were no pools or other bodies of water observed. 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. There following violation(s) of the California Code of Regulations, Title 22; Division 12, was observed during today’s visit. 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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2023 01:02 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: SIMMONS, NINA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483001979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2023

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
1 2 3 4	Based on the Licensee's (LS) statement confirming she did not have evidence of TB clearance available for S3. 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: 04/12/2023
	Plan of Correction
1 2 3 4	The Licensee stated she would ensure S3 obtain evidence of negative TB clearance and LS intends to submit S3's evidence of negative TB clearance to the Department by 04/12/23 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	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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