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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008718
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:51:57 PM


Document Has Been Signed on 06/09/2023 03:51 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CLAVERIE, CLAUDIA FCCHFACILITY NUMBER:
483008718
ADMINISTRATOR:CLAVERIE, CLAUDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 704-7221
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:14CENSUS: 6DATE:
06/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Claudia Claverie - LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analysts (LPAs) Selena Mariani and Mel Augustin made an unannounced case management visit and met with Licensee, Claudia Claverie (LS) to deliver several deficiencies observed. LPAs observed 6 children in care that did not seemed to be in distress, there was a construction crew on the right side of the home that was repairing a retaining wall. LS also stated she was unaware of the requirement to notify the Department of alterations to the home. Additionally, LPAs reviewed three staff (LS, S1 and S2) records at 2:11 pm which revealed LS, S1 and S2 were missing required immunization records and according to LS, S2 was a former staff that assisted in providing care and supervision to the children for approximately six days. During the visit LS did not furnish required staff immunization records and stated she couldn't provide the immunization records.

LPAs consulted on the requirements for LS to notify the Department of construction projects prior to alteration and furthermore, LS understood all staff are required to obtain immunization records and accordance with health and safety code 1597.622(a)(1).

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. The following violation(s) of California Code of Regulations, Title 22, Division 12, were cited during today's visit. Appeal Rights were provided.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Selena MarianiTELEPHONE: (916) 605-8974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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Document Has Been Signed on 06/09/2023 03:51 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CLAVERIE, CLAUDIA FCCH
FACILITY NUMBER: 483008718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2023
Section Cited
CCR
102416.3(a)

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Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed change.

This requirement is not met as evidence by: Based on LPAs observations of current constructions taking place to repair a retaining wall, on the right side of the home.
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LS states she will email a statement detailing how she intends to comply with 102416.3(a) to LPA Selena Mariani and stated moving forward LS will provide notification prior to initiating home improvements.
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However, the Licensee did not notify the Department prior to the start of the project and this poses a potential health, safety and/or personal rights risk to children in care.
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Type B
06/19/2023
Section Cited
HSC1597.622(a)(1)

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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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LS states in the future will require staff to fill out and turn in all paperwork prior to their first day of work, furthermore LS stated she and S1 will ensure all staff obtain required immunization records and LS intends to submit evidence to the Department by 6/19/2023.
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This requirement is not met as evidence by: Based on staff records reviewed conducted by LPA which revealed
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Selena MarianiTELEPHONE: (916) 605-8974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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