483009907-3-11-2022-01-CC-MAUN-CCEUCX-20220311142828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009907
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:28:39 PM

Document Has Been Signed on 03/11/2022 02:28 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:	WADDELL, ANTOINISHA FCCH		FACILITY NUMBER:	483009907
ADMINISTRATOR:	WADDELL, ANTOINISHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 373-3363
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	14	CENSUS: 9	DATE:	03/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Antoinisha Waddell- Licensee		TIME COMPLETED:	02:40 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 03/11/2022 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 is currently one adult 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. The facility is partnered with Child Start Inc. and did not have any standing waiver(s). During today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising nine 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 6:00AM to 6:00PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms, one bathroom, living room, kitchen, garage and backyard were made inaccessible by children’s safety gates. The home was clean and orderly and was at a comfortable indoor temperature. The fireplace was screened by children’s safety gate. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification expire on 03/15/22. 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 fire extinguisher rated at least 2A10BC. The Licensee reported there were no poison(s) stored at the facility. LPA reviewed eight children's (C1-C8) at 10:38am which revealed C3 was missing first page of identification and emergency information (LIC 700) and C7’s LIC 700 was incomplete and not signed by parent. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WADDELL, ANTOINISHA FCCH	FACILITY NUMBER: 483009907
	VISIT DATE: 03/11/2022

NARRATIVE

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Additionally, C7 was missing Immunization Records (IR) and LIC 627; and C1-C8’s IR were not transcribed onto blue CDPH 286. Three staff (S1-S2 & LS) records reviewed at 11:13am which revealed the records contained Criminal Record Statement (LIS 508), Employee Rights (LIC 9052), completed LIC 9108, current AB 1207 Mandated Reporter Training certificates, evidence of negative TB clearance and staff required Immunization Record (IR).

The facility conducted an emergency drill within the past six months and the last drill was conducted on 02/08/22. The facility roster of the children in care was reviewed and appeared to be complete. Licensee stated there were no firearm(s) and/or other dangerous weapons stored in the home. During today's inspection, LPA observed a sprayer filled with unknown compound and a shed with broken window in the backyard, and there were no child(ren) playing in the fully fenced backyard. Licensee stated the children had not played in the backyard since September or October 2021 due to flooding caused by recent storms, and Licensee provided an updated Facility Sketch (LIC 999) to place the backyard off limits. 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. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WADDELL, ANTOINISHA FCCH	FACILITY NUMBER: 483009907
	VISIT DATE: 03/11/2022

NARRATIVE

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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: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/11/2022 02:28 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: WADDELL, ANTOINISHA FCCH	FACILITY NUMBER: 483009907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on eight children's (C1-C8) records reviewed at 10:38am which revealed C7 was missing Immunization Records (IR) and LIC 627. Additionally, C3 & C7's LIC 700 were incomplete and not signed by parent(s). 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: 03/21/2022
	Plan of Correction
1 2 3 4	Licensee stated she would obtain Immunization Records (IR) from C7's parents and she would provide C3 & C7's parents with LIC 700 and obtain the completed form to submit to the Department by 03/21/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Type B

Section Cited

CCR

102418(g)(1)

Immunizations

(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
1 2 3 4	Based on eight children's (C1-C8) records reviewed at 10:38am which revealed C1-C8's Immunization Records (IR) were not transcribed onto the blue CDPH 286. 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: 03/21/2022
	Plan of Correction
1 2 3 4	Licensee stated she would transcribed the children's Immunization Records onto the blue CDPH 286. LPA provided a copy blank CDPH 286 and LIC 9098 for Licensee to complete and submit with completed CDPH 286 by 03/21/22. 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: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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