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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007467
Report Date: 02/16/2022
Date Signed: 02/16/2022 12:22:47 PM


Document Has Been Signed on 02/16/2022 12:22 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, MARENA FCCHFACILITY NUMBER:
483007467
ADMINISTRATOR:SIMMONS, MARENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 557-1101
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:14CENSUS: 6DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marena Simmons-LicenseeTIME COMPLETED:
12:45 PM
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 02/16/2022 indicates that all facility staff or other individuals who require caregiver background checks receive a criminal record and child abuse index clearances or exemptions. There is currently one adult 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 six children (C1-C6) 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 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 pediatric CPR/First Aid certification expire on 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 2A10BC fire extinguisher at the facility. LPA did not observe any poison(s).

During today’s inspection, there were no infant(s) under 24 months old in care and LS stated she currently did not provide infant care, and she did not have any pack and plays available. Staff records were reviewed at 9:18am which revealed LS and S1’s records contained current AB 1207 Mandated Reporter Training certificates, evidence of negative TB clearance; and required staff immunization records. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
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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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, MARENA FCCH
FACILITY NUMBER: 483007467
VISIT DATE: 02/16/2022
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The fireplace was screened with multiple storage bins. LPA reviewed six children’s (C1-C6) records at 10:05am and records reviewed contained identification and emergency information forms, parents’ rights, the children’s Immunization records (IR), however; C4’s LIC 282 and LIC 627 did not contain the child's authorized representative's signature, and a Technical Violation was issued for this deficiency.

The facility conducted at least one emergency disaster drill within six months and the last drill was conducted on 12/15/21. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee stated there were no firearms and/or other dangerous weapons in the home, and none were observed. 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 were no violation(s) of the California Code of Regulations, Title 22; Division 12.



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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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