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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007966
Report Date: 01/06/2020
Date Signed: 01/06/2020 02:51:57 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:PLUMP, SHIRLEY FCCHFACILITY NUMBER:
483007966
ADMINISTRATOR:PLUMP, SHIRLEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 246-6596
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:14CENSUS: 0DATE:
01/06/2020
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Shirley PlumpTIME COMPLETED:
03:00 PM
NARRATIVE
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An Annual/Random inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 01/06/20 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 are currently three adults living in the home.

During today’s inspection the home and grounds were toured. The licensee did not have any children in care, 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, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the two bedrooms & one bathroom on the upper level of the home, 3 bedrooms on the lower level, and garage, and were made inaccessible by door locking mechanism. The home was clean and orderly, and was at a comfortable indoor temperature of 65 degrees Fahrenheit. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 10/2020. At 1:15pm, LPA requested the Licensee's AB 1207 Mandated Reporter Training certificate, however, the Licensee could not furnish proof that she completed the AB 1207 Mandated Reporter Training. The Licensee could not furnish her proof of immunity against the Pertussis and Influenza. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Poisons are locked in the garage. The fireplace has been made inaccessible with a glass screen. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. 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 back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. 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.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2020
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 3
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: PLUMP, SHIRLEY FCCH
FACILITY NUMBER: 483007966
VISIT DATE: 01/06/2020
NARRATIVE
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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: 01/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: PLUMP, SHIRLEY FCCH
FACILITY NUMBER: 483007966
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2020
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 the Licensee's failure to furnish her AB 1207 Mandated Reporter Training certificate. This poses a potential health, safety, or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Public Email: cclrpregionalofficegeneral@dss.ca.gov
Type B
01/27/2020
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 the Licensee's failure to furnish her proof of immunity against the Pertussis and Influenza to LPA. This poses a potential, health, safety, or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
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: 01/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3