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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009622
Report Date: 08/06/2019
Date Signed: 08/06/2019 09:56:29 AM

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:BELL, MIESHA FCCHFACILITY NUMBER:
483009622
ADMINISTRATOR:BELL, MIESHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-5973
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:14CENSUS: 7DATE:
08/06/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Miesha BellTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Melchisedeck Augustin made an unannounced follow up Plan of Correction (POC) inspection at the facility, in response to the Licensee's failure to submit POC for two type B deficiencies that were cited on 07/08/19. On 07/08/19, the Licensee was cited for failing to furnish proof of a negative Tuberculosis clearance and proof immunity against the Measles, Pertussis and Influenza for S1, S3 & S4. The Licensee's POC for both type B deficiencies were due on 07/29/19. On 07/29/19, the Licensee requested an extension on her POC due date. LPA extended the Licensee's POC due dates to 08/02/19. On 07/31/19, the Licensee submit proof of negative TB for S1. During today's inspection, LPA met with Licensee Miesha Bell and LPA discussed the purpose of the inspection with the Licensee. LPA requested from the Licensee, proof of immunity against the Measles, Pertussis and Influenza for S1, S3 & S4. At 9:05am, the Licensee claimed S3 is scheduled to return to his medical provider to obtain his proof of negative TB clearance and proof of immunity against the Measles, Pertussis and Influenza on 08/07/19. The Licensee claimed that S3 will not be present and around the children until S3 obtains proof of a negative TB and proof of immunity against the Measles, Pertussis and Influenza. The Licensee claimed that S4 will not be returning to the facility. LPA requested from the Licensee, a signed letter from S4 that details that S4 does not intend to return to the facility. The Licensee has requested an extension on her POC due date for both deficiencies that were due by 08/02/19. The Licensee's POC due date for both type B deficiencies are being extended to 08/08/19.

This report was discussed and reviewed with the Licensee. Notice of Site Visit shall be posted for 30 days from today's inspection. There were no Title 22 deficiencies cited during today' inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
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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