483003223-5-27-2022-01-CC-MAUN-CETSTD-20220527140921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483003223
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:09:36 PM

Document Has Been Signed on 05/27/2022 02:09 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:	PETERSEN-LAWSON, SHELETTA FAMILY CHILD CARE HOME		FACILITY NUMBER:	483003223
ADMINISTRATOR:	PETERSEN-LAWSON, SHELETTA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 553-9809
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	14	CENSUS: 9	DATE:	05/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Sheletta Petersen-Lawson - Licensee		TIME COMPLETED:	02:20 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 05/27/2022 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. The Licensee (LS) and one staff (S1) were supervising nine 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 6:00am to 6:00pm, 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 were made inaccessible by door locking mechanism. 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. 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. LPA did not observe any poison(s). The Licensee stated there were no firearm(s) or other dangerous weapons stored on site. Two staff (LS & S1) records were reviewed at 10:54am which contained staff required immunization record, evidence of negative TB clearance, AB 1207 Mandated Reporter Training certificate, and Employee Rights. (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: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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 05/27/2022 02:09 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: PETERSEN-LAWSON, SHELETTA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483003223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the Licensee not furnishing evidence to prove that 15 minutes checks had been conducted for napping infant(s). 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: 06/10/2022
	Plan of Correction
1 2 3 4	The Licensee stated she would document 15 minute checks on the Sleep Log the next time C10 is in care and the Licensee would submit evidence to prove that 15 minutes are being conducted for C10 to the department by 06/10/22 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: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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: PETERSEN-LAWSON, SHELETTA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483003223
	VISIT DATE: 05/27/2022

NARRATIVE

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Nine children’s (C1-C9) were reviewed at 11:43am and the records consisted of identification and emergency information forms (LIC 700), Immunization Records (IR), Consent for Emergency Medical Treatment (LIC 627) and IR were transcribed onto the blue CDPH 286 form.

During today’s inspection, Licensee stated one child under 24 months old was enrolled into care and during the visit, LPA did not see any child(ren) under 24 months old in care. Licensee did not furnish evidence to proof that 15-minute checks had been conducted for C10. There were two play yards which contained framed enclosure with integrated mesh or fabric sides that were available. The facility conducted an emergency disaster drill within the past six months and the last drill was conducted on 03/14/22. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee had an EMSA approved pediatric CPR/First Aid certificate which expire on 09/26/2022.

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. 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.

(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: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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: PETERSEN-LAWSON, SHELETTA FAMILY CHILD CARE HOME	FACILITY NUMBER: 483003223
	VISIT DATE: 05/27/2022

NARRATIVE

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A notice of site visit was given and must remain posted for 30 days. 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 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.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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