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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
483007352
Report Date:
10/05/2022
Date Signed:
10/05/2022 03:55:58 PM
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
ADMINISTRATOR:
BLAIR, JENNIFER
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(707) 553-8733
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94591
CAPACITY:
14
CENSUS:
9
DATE:
10/05/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:46 AM
MET WITH:
Jennifer Blair - Licensee
TIME COMPLETED:
04:20 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analysts (LPAs), M. Augustin and C. Fernandes-Goes. A review of staff records on 10/05/2022 indicates that all facility staff or other individuals who require caregiver background checks have not received criminal record and child abuse index clearances or exemptions. Licensee stated three adults currently reside in the home, however; one adult (A1) had not obtained a criminal record clearance as well as Department records indicated only two adults obtained a criminal record clearance. An interview with Licensee, (LS) confirmed A1 resided in the home for at least five days and LS did not furnish evidence of negative TB clearance for A1, and an immediate $500 civil penalty was assessed for violation of criminal record clearance requirements. 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 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 7:30am - 5:30pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the four bedrooms and two bathroom, living/dining area kitchen and garage, and were made inaccessible by means of a children safety gate.
There is a working telephone in the home. There is a functional smoke detector and carbon monoxide detector; and a fully charged fire extinguisher rated at least 2A10BC. The top of the staircase near the living room was barricaded with a child safety gate. The fireplace was screened with a child safety gate. LPA did not observe any poison(s). There were no firearm(s) or other dangerous weapons stored on the premise. (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:
10/05/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
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
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Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee's statement which confirmed three adults resided in the home, A1 was at least 18 years in age and resided in the home and Department records confirming only two adults obtained a criminal record clearance. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/06/2022
Plan of Correction
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LPA informed Licensee that all adult 18 years and older residing in the home was required to obtained an approved criminal record clearance. Licensee stated she would send A1 to the UPS vendor to get Live Scan fingerprinted on 10/05/22 or by 10/06/22. The Licensee stated after A1 gets Live scan, Licensee would sbumit a copy of the LIC 9163 to the Department by 10/06/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
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
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Based on the Licensee's (LS) statement confirming she did not document 15 minute checks while C1 & C2 napped and LS not furnishing evidence to prove 15 minutes checks were conducted. 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:
10/19/2022
Plan of Correction
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Licensee stated she would make additional copies of the Sleep Log and she would document seven days worth of 15 minute checks on the Sleep Log for C1 & C2, and the Licensee would submit evidence to prove that she initiated 15 minute checks for the infants while they napped. Email: melchisedeck.augustin@.dss.ca.gov & FAx: 707-588-5099
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day 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
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Based on the Licensee's (LS) statement validating she and S1 had not completed the training and LS not furnishing a current AB 1207 Mandated Reporter Training certificates for LS & S1. 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:
11/19/2022
Plan of Correction
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Licensee stated she and S1 would complete the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and LS would submit the current certificates to the Department by 11/19/22 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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
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
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Based on LPAs' observations of the Licensee's (LS) pediatric CPR/First Aid certification which was expired and LS not furnishing a current EMSA approved CPR/First Aid certification for LS or S1. 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:
10/26/2022
Plan of Correction
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LIcensee stated she would enroll in an EMSA approved Pediatric CPR/First Aid training, complete the training and submit a copy of her current certificateion to the Department by 10/26/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing records for S1. 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:
10/26/2022
Plan of Correction
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Licensee stated she would produce and personnel record for S1 and Licensee would submit a written statement certifying that she created a personnel record for S1.
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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Department records which revealed the Licensee did not submit submit an updated application (LIC 279) to report three adults resided in the home. 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:
10/26/2022
Plan of Correction
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Licensee submitted an updated LIC 279 to list the adults residing in the home and the Licensee agreed to produce a written statement to detailing how she intends to report changes at the facility and comply with the the regulations.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(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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Based on the Licensee not furnishing proof of immunity against Pertussis for S1. 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:
10/26/2022
Plan of Correction
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Licensee stated she would obtain and submit required immunization for S1 to the Department by 10/26/22. 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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(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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2
3
4
Based on five children's (C1-C5) records reviewed at 11:23am which revealed C2 & C5's LIC 700 were either incomplete or not signed by the child's parent or authorized representative. 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:
10/05/2022
Plan of Correction
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Licensee stated she would submit verification to prove the licensing forms were either completed or signed by the child's parent or authorized representative.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on five children's (C1-C5) at 11:23am which revealed C2's record was missing Immunization Record (IR) and IR was not transcribed onto the 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:
10/26/2022
Plan of Correction
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3
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Licensee stated she requested IR from C2's parent and the Licensee would obtain C2's immunization record from the parent and Licensee would submit evidence to show C2 was immunized prior to enrollment into care. The Licensee would submit her POC to the Department by 10/26/22 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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
10/05/2022 03:55 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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/05/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 five children's (C1-C5) records reviewed at 11:23am which revealed a child (C2) under 12 months old did not have a completed 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:
10/26/2022
Plan of Correction
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2
3
4
Licensee stated she would provide C2's parent with the LIC 9227 for completion, and Licensee would submit a copy of the completed LIC 9227 to the Department by 10/26/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
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) stated confirming an adult (A1) resided in the home, and LS not furnishing evidence of negative TB clearance for A1. 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:
10/26/2022
Plan of Correction
1
2
3
4
Licensee stated she would ensure A1 obtained evidence of negative TB clearance and Licensee would submit evidence of negative TB clearance for A1 to the Department by 10/26/22 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:
10/05/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
7
of
11
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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
VISIT DATE:
10/05/2022
NARRATIVE
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LPAs requested records for two staff (LS & S1), however; Licensee did not furnish staff records. LS did not furnish current AB 1207 Mandated Reporter Training certificate for S1 & LS and proof of immunity against the Pertussis for S1.
At 11:23am, LPAs reviewed five children’s records (C1-C5) which revealed C1, C2 & C5’s records either had an incomplete LIC 700, missing Individual Infant Sleep Plan (LIC 9227), missing Immunization Record (IR) and/or IR was not transcribed onto the CDPH 286.
During today’s inspection, LPAs observed two children (C1 & C2) under 24 months old enrolled in care and there was a total of two play yards available for each infant to use. The Licensee did not furnish evidence to prove she was conducting 15-minute checks while C1 & C2 napped. The facility conducted an emergency disaster drill within the past six months and the last drill was documented on 08/16/22. The facility roster of the children in care was reviewed and appeared to be incomplete. The Licensee did not furnish a current EMSA approved pediatric CPR/First Aid certification. There is a hot tub that is covered and securely locked on all corners and the hot tub was fully enclosed in wrought iron fencing that was at least five feet in height and met fencing requirements. The backyard was fully fenced and 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
. LPAs 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:
10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
10
of
11
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:
BLAIR, JENNIFER FCCH
FACILITY NUMBER:
483007352
VISIT DATE:
10/05/2022
NARRATIVE
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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, Jennifer Blair. The following violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s visit. Appeal Rights were provided.
LPA M. Augustin
informed licensee, Jennifer Blair that this report dated 10/05/2022 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA M. Augustin informed the licensee to provide a copy of this licensing report dated 10/05/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
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:
10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/05/2022
LIC809
(FAS) - (06/04)
Page:
11
of
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