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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009622
Report Date: 08/23/2019
Date Signed: 08/23/2019 09:20:45 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: 6DATE:
08/23/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Miesha BellTIME COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Melchisedeck Augustin made an unannounced follow up Case Management inspection at the facility, in response to the Licensee's failure to submit POC for type B deficiency that was cited on 07/08/19. On 07/08/19, the Licensee was cited for failing to furnish proof immunity against the Measles, Pertussis and Influenza for S1, S3 & S4; and the Licensee's POC for type B deficiency was 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 08/08/19, the Licensee submitted proof of immunity against the Measles Pertussis and Influenza for S1 and S2. The Licensee submitted three different immunization records for S3 which indicates that S3 has proof of immunity against the Pertussis and Influenza, however, the information on the immunization records for proof of immunity against the Measles are inconsistent with each other.

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 for S3 and the Licensee stated that she did not have S3's immunization records available at the facility. LPA had a discussion with the Licensee about the inconsistent information in S3's immunization and that S3 is missing proof of immunity against the Measles. The Licensee stated that she understands and acknowledges that the information on all three immunization records are inconsistent with each other. The Licensee stated she will request for S3 to get a Titer blood test, to test for S3's immunity against the Measles. The Licensee requested an extension on her POC due date. LPA has extended the POC Due date to 09/02/19. 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 deficiency cited during today's inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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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