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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483003054
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:27:06 PM


Document Has Been Signed on 10/13/2023 01:27 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:STOVALL, CINDY FAMILY CHILD CARE HOMEFACILITY NUMBER:
483003054
ADMINISTRATOR:STOVALL, CINDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 448-8775
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 10DATE:
10/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Cindy Stovall - LicenseeTIME COMPLETED:
01:40 PM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analyst (LPA), Melchisedeck Augustin conducted a Case Management visit and met with Licensee (LS), Cindy Stovall, to deliver several deficiencies that were observed. LPA reviewed three staff (LS & S1-S2) at 11:44am which revealed LS & S1 were missing required staff immunization records, and LS confirmed S2 sometimes worked at the facility, however; LS did not furnish records for S2.

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, Cindy Stovall. The following violation of California Code of Regulations, Title 22, Division 12, was cited during today's visit. Appeal Rights were provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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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Document Has Been Signed on 10/13/2023 01:27 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: STOVALL, CINDY FAMILY CHILD CARE HOME
FACILITY NUMBER: 483003054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
HSC
1597.622(a)(1)

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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:
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Licensee stated she would request and obtain all required immunization, and LS would submit evidence of required staff immunization records to the Department by 10/27/23 via mail, email or fax.
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Based on LPA's review of three staff (LS & S1-S2) which revealed LS & S1-S2 were missing required staff immunization records. This poses/posed a potential health, safety and/or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
10/27/2023
Section Cited
CCR102416.1(d)

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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: Based on the Licensee's statement confirming S2 worked at the facility, however;
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Licensee stated she would ensure S2's record was complete and Licensee intends to submit complete records for S2 to the Department by 10/27/23 via mail, email or fax.
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LS did not furnish records for S2.
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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: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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