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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007592
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:07:36 PM


Document Has Been Signed on 12/06/2023 03:07 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:VAEZINIA, VICTORIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
483007592
ADMINISTRATOR:VAEZINIA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 452-8888
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 10DATE:
12/06/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Victoria Vaezinia - LicenseeTIME COMPLETED:
03:15 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 12/06/2023 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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 10 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 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 second floor, family room and garage were made inaccessible by means of children’s safety gates. The staircase near the front entrance was barricaded with a child safety gate. The fireplace screen door was locked and inaccessible. The home was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification expire 09/08/2025. 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. The Licensee stated she did not store any firearm(s) or other dangerous weapon(s) on the premise. LPA did not observe any poison(s). LPA reviewed three staff (LS & S1-S2) records at 12:12pm, which revealed LS and S1-S2 were missing a current AB 1207 Mandated Reporter Training certificates, and S1-S2’s records were missing required 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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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: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592
VISIT DATE: 12/06/2023
NARRATIVE
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LPA reviewed six children’s (C1-C6) records at 12:44pm which revealed C1-C3 & C5-C6’s records were either missing or did not contain Identification and Emergency Information form (LIC 700), and Notification of Parent’s Rights (LIC 995A), and/or Immunization Records (IR) were incomplete or was not transcribed onto the blue CDPH 286. According to the facility’s disaster drill log, the facility conducted an emergency drill within the past six months and the last drill was documented on 09/12/23. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee confirmed there were a total of three children under 24 months old enrolled into care, and during the visit two infants (C1 & C5) were present, and the Licensee did not furnish evidence to prove she did/had conducted 15-minute checks while C1 & C5 took a nap. LPA did not observe any bodies of water.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

On this date, 12/06/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. (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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592
VISIT DATE: 12/06/2023
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview conducted and report was reviewed with the Licensee, Victoria Vaezinia. 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. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/06/2023 03:07 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: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

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
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Based on the Licensee not furnishing evidence to prove she documented 15 minute checks while C1 & C5 took a nap. 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: 12/16/2023
Plan of Correction
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LPA provided the Licensee with several copies of a blank Sleep Logs, and Licensee agreed to document five days worth of 15 minute checks, and intend to submit completed logs for all infant by 12/16/23 via mail, email or fax. 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 three staff (LS & S1-S2) records reviewed at 12:12pm which revealed LS & S1-S2 were missing a current AB 1207 Mandated Reporter Training certificates. 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: 12/16/2023
Plan of Correction
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Licensee stated she and S1-S2 would complete the online AB 1207 Mandated Reporter training module at mandatedreporterca.com, and Licensee intends to submit current certificates for herself and staff to the Department by 12/16/23. 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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 12/06/2023 03:07 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: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 three staff (LS & S1-S2) records reviewed at 12:12pm which revealed S1 & S2 were missing required staff immunization records. 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: 12/16/2023
Plan of Correction
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Licensee stated she would ensure S1 & S2 obtained proof of immunity against Measles, Pertussis and Influenza, and Licensee intends to submit evidence of staff immunization record to the Department by 12/16/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) 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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on six children's (C1-C6) recoreds reviewed at 12:44pm which revaled C1-C2 & C5-C6 were missing transcribed 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: 12/16/2023
Plan of Correction
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Licensee stated she would review the children's records and ensure she transcribed the Immunization Records onto the current blue CDPH 286, and Licensee intends to submit evidence of transcribed CDPH 286 to the Department by 12/06/23 via mail, email or fax.
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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 12/06/2023 03:07 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: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on six children's (C1-C6) records reviewed at 12:44pm which revealed C2 was missing parents rights. 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: 12/16/2023
Plan of Correction
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Licensee stated would ensure she provided C2's parent with LIC 99A for signature, obtain the signature and submit the completed form to the Department by 12/16/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6