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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008850
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:12:48 PM


Document Has Been Signed on 07/18/2023 04:12 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:ROERDEN, ALLISON FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008850
ADMINISTRATOR:ROERDEN, ALLISONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 718-7505
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 11DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee Allison RoerdanTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Elpidia Hernandez Torres arrived to the facility to conduct a case management visit, while attending to other matters in the facility LPA observed Adult (A1), in the facility who did not have background clearance on file and was not associated to the facility. Type A deficiency was cited and An immediate Civil penalty of $500 was issued on attached 809-D.

While LPA was present in the home A1 went out and got fingerprinted and gave LPA a copy of completed LIC 9163.

A notice of site visit was given and must remain posted for 30 day, along with the report and Type A citation. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Licensee was also informed of the requirement to provide a copy of any licensing report that documents a Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/ guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Exit interview conducted and report was reviewed with the licensee Allison Roerden.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 07/18/2023 04:12 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: ROERDEN, ALLISON FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
102370(d)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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Licensee printed LIC 9163 While LPA was present in the home A1 went out and got fingerprinted at UPS nearby. LPA took picture of completed LIC 9163.
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Based on observation and interview, Licencee's Son lives in the home but did not get fingerprint clearance through CCL and Is not associated to the facility. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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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: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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