483009502-1-19-2022-01-CC-MAUN-CATTD2-20220119133737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009502
Report Date: 01/19/2022
Date Signed: 01/19/2022 01:37:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	JOHNSON, JENIQUE FCCH		FACILITY NUMBER:	483009502
ADMINISTRATOR:	JOHNSON, JENIQUE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 586-2907
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	14	CENSUS: 2	DATE:	01/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jenique Johnson		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 01/19/2022 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 two adults 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) was supervising two 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 9:00PM, Mon–Sat. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms, one bathroom and garage, and were made inaccessible by plastic doorknob covers. The home was orderly and was at a comfortable indoor temperature. The fireplace was screened by a wooden particle board. There were safe toys and equipment available for children. There is a working telephone in the home. The CPR/First Aid certification did not meet the Department’s requirements. LS did not furnish a current AB 1207 Mandated Reporter Training certificate for LS and S1. 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. The Licensee stated that poisons were not stored on site and LPA did not observe any poison during the inspection. The facility conducted an emergency drill on 01/19/22. The facility roster of the children currently in care was reviewed and appeared to be complete. LPA reviewed two children’s (C1 & C2) records at 10:49am, and emergency and identification forms and required immunization were on file, however; C1 & C2’s record were missing parents’ rights (LIC 995). LPA issued a Technical Violation for this deficiency.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: JOHNSON, JENIQUE FCCH	FACILITY NUMBER: 483009502
	VISIT DATE: 01/19/2022

NARRATIVE

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Staff (LS, S1) records were reviewed at 11:02am and records reviewed revealed that S1’s record was missing proof of immunity against Measles, Pertussis and Influenza. The Licensee stated there were no firearms and/or other dangerous weapons in the home. The backyard appeared to be free of hazards and was fully fenced. There were no pools or other bodies of water observed in the yard.

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. Exit interview conducted and report was reviewed with the Licensee.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: JOHNSON, JENIQUE FCCH	FACILITY NUMBER: 483009502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation which revealed that the CPR/First Aid was not EMSA approved and did not meet the Department's requirements. 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: 02/02/2022
	Plan of Correction
1 2 3 4	The Licensee stated she would contact the vendor and obtain an EMSA approved Pediatric CPR/First Aid certification and submit a copy of her current certificate to the Department by 02/02/22.

Type B

Section Cited

HSC

1597.622(a)(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
1 2 3 4	Based on staff record reviewed at 11:02am which revealed that S1 was missing proof of immunity against the Measles, Pertussis and Influenza. 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: 02/02/2022
	Plan of Correction
1 2 3 4	Licensee stated she would obtain proof of immunity against the Measles, Pertussis and Infleunza for S1 and she would submit S1's required immunization record to the Department by 02/02/22 via mail, email or fax. 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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: JOHNSON, JENIQUE FCCH	FACILITY NUMBER: 483009502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

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 completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records reviewed at 11:02am which revealed that LS and S1 were missing 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: 03/05/2022
	Plan of Correction
1 2 3 4	The Licensee stated she and S1 would complete the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com and Licensee would submit a copy of the current certificates to the Department by 03/05/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

Page: 5 of 5