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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007467
Report Date: 02/07/2020
Date Signed: 02/07/2020 03:17:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SIMMONS, MARENA FCCHFACILITY NUMBER:
483007467
ADMINISTRATOR:SIMMONS, MARENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 557-1101
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:14CENSUS: 4DATE:
02/07/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Marena SimmonsTIME COMPLETED:
03:30 PM
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 02/07/20 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 is currently one adult living in the home.

During today’s inspection the home and grounds were toured. The licensee and one assistant (S1) were supervising four 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 7:00am to 10:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are two bedrooms, one bathroom, living/dining room and kitchen, and were made inaccessible by children's safety gate. Care is primarily provided in the converted garage. The home was observed to be clean and orderly, and was at a comfortable indoor temperature of 69 degrees Fahrenheit. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed, and expire on 10/12/21. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. LPA did not observe any poison. The fireplace has been made inaccessible with a screen. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 12/13/19. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The children use the backyard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed. Two children's (C1 & C2) record were reviewed at 1:03pm; Notification of Parent’s Rights forms were on file for C1 & C2, however, C1 and C2's immunization were not transcribed onto the CDPH 286. Two staff (S1 & S2) records were reviewed at 1:15pm and staff records reviewed revealed S1 is missing proof of immunity against the Measles and Pertussis; and S2 is missing AB 1207 Mandated Reporter Training certificate.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SIMMONS, MARENA FCCH
FACILITY NUMBER: 483007467
VISIT DATE: 02/07/2020
NARRATIVE
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The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SIMMONS, MARENA FCCH
FACILITY NUMBER: 483007467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2020
Section Cited

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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
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completed the initial mandated reporter training.
This requirement is not met as evidenced by: Based on staff records reviewed revealing that S2 is missing AB 1207 Mandated Reporter Training certificate at 1:15pm. This poses a potential health, safety or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Public email: cclrpregionalofficegeneral@dss.ca.gov
Fax: 707-588-5099
Type B
02/21/2020
Section Cited

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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.
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This requirement is not met as evidenced by: Based on staff records reviewed conducted at 1:15pm. Staff records reviewed revealed that S1 is missing proof of immunity against the Measles and Pertussis. This poses a potential health, safety or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Public email: cclrpregionalofficegeneral@dss.ca.gov
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: 02/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SIMMONS, MARENA FCCH
FACILITY NUMBER: 483007467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
Section Cited

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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: Based on two children's records reviewed at 1:03pm.
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Children's records reviewed revealed that C1 and C2 were missing transcribed CDPH 286. This poses a potential health, safety or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Public email: cclrpregionalofficegeneral@dss.ca.gov
Fax: 707-588-5099

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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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4