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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009797
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:08:39 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:SMITH, LATISSA FCCHFACILITY NUMBER:
483009797
ADMINISTRATOR:LATISSA SMITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-4839
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:14CENSUS: 1DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Latissa SmithTIME COMPLETED:
03:15 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analysts (LPAs), M. Augustin and E. Hernandez Torres. A review of staff records on 11/04/2021 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.

During today’s inspection the home and grounds were toured. The licensee was supervising one child, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 10:00AM to 11:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire first floor, kitchen and the backyard. They were made inaccessible by a child's safety gate. The home was clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee produced pediatric CPR and First Aid certification, which expire on 10/2023. Licensee also produced AB 1207 Mandated Reporter Training certificate which expire on 09/21/2023. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. At 10:08am, LPAs observed the top and bottom of the staircase near the front entrance was not barricaded, however; the Licensee barricaded the staircase before LPAs completed the inspection. At 10:36am, LPAs observed the 2A10BC fire extinguisher was not charged, however; before the end of the inspection, the Licensee furnished a fully charged fire extinguisher. At 10:55am, LPAs observed a canister of Hot shot poison in the on limits bathroom drawer, and LPAs reviewed CCR regulations indicating that poison(s) are to be either key or combination locked. During record review at 11:56am, C1 was missing LIC 700 and the immunization record was not transcribed onto the blue CDPH 286. Two potential risk violations were issued for these deficiencies. The fireplace on the first floor was in the off limits are and was made inaccessible with a child safety gate. There is a working smoke detector and carbon monoxide detector. The licensee stated there were no firearms and/or other dangerous weapons in the home. The children utilized the local community park as the outdoor play area. There were no pools or other bodies of water observed in the yard. The licensee is not providing Incidental Medical Services (IMS) to children in care.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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: SMITH, LATISSA FCCH
FACILITY NUMBER: 483009797
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. At 10:36am, the 2A10BC fire extinguisher was not fully charged which poses/posed a potential health, safety or personal rights risk to persons in care .
POC Due Date: 11/04/2021
Plan of Correction
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The Licensee furnished a fully charged 2A10BC fire extinguisher before LPAs completed the inspection, clearing this deficiency.
Type B
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Upon arrival, there was one child under the age of five years old present and LPAs observed the staircase near front entry was not barricaded which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2021
Plan of Correction
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At 10:42am, the Licensee barricaded the top of the staircase with a child safety gate, clearing this deficiency.
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: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 2 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: SMITH, LATISSA FCCH
FACILITY NUMBER: 483009797
VISIT DATE: 11/04/2021
NARRATIVE
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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.

LPAs 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.

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

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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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: SMITH, LATISSA FCCH
FACILITY NUMBER: 483009797
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. At 11:27am, the Licensee had not transcribed C1's immunization record onto the CDPH 286, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2021
Plan of Correction
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The Licensee stated she would print out blank CDPH forms and transcribe C1's immunization onto the blank form. The Licensee stated she would submit C1's transcribed CDPH 286 to the Department by 11/11/21 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5