485407546-9-8-2022-01-CC-MAUN-CJ3VGY-20220908162618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 485407546
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:26:38 PM

Document Has Been Signed on 09/08/2022 04:26 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:	NAEBKHEL, SURYA FAMILY CHILD CARE HOME		FACILITY NUMBER:	485407546
ADMINISTRATOR:	NAEBKHEL, SURYA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 600-8145
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	14	CENSUS: 5	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Surya Naebkhel -Licensee		TIME COMPLETED:	04:35 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 09/08/2022 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 six 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) and two adults (A1 & A2) were supervising five daycare children (C1-C5), and the facility was operating within the licensed capacity and ratio requirements. LPA observed A1 & A2 was sitting close and picking up daycare children. No children were observed left in any parked vehicle. The facility’s operating hours are Monday - Friday; 7:00am - 5:00pm. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms and two bathrooms on the second floor, kitchen and backyards are off limits to the children, and these areas have been made inaccessible by means of door locking mechanism and large sofas to barricaded passage. There is a working telephone in the home. There is a functional smoke detector and carbon monoxide detector; and a fully charged fire extinguisher rated at least 2A10BC. There was a child safety gate installed at the bottom of the staircase, however; the gate did not securely barricade the staircase. LPA did not observe any poison(s). There were no firearm(s) or other dangerous weapons stored on the premise. (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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: NAEBKHEL, SURYA FAMILY CHILD CARE HOME	FACILITY NUMBER: 485407546
	VISIT DATE: 09/08/2022

NARRATIVE

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Five children’s (C1-C5) records were reviewed at 1:00pm which revealed C1, C2 & C4 were missing Immunization Record (IR) and IR was not transcribed onto the CDPH 286.

During today’s inspection, there were two children (C2 & C4) under 24 months old enrolled in care and Licensee did not furnish evidence to prove that 15 minute-checks had/was being conducted while C2 & C4 napped. Licensee did not furnish evidence to prove she conducted at least one emergency disaster drill within six months. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee's EMSA approved pediatric CPR/First Aid certification expire on 07/17/23. The backyard is off limits and appeared to be fully fenced. There is a large and permanent water fountain fixture installed in the backyard, the fountain was drained of its water and was not fenced and glass sliding door as well as five interior windows allowed access to the yard. LPA issued a Technical violation for this deficiency.

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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. 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 cited during today’s visit.

(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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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: NAEBKHEL, SURYA FAMILY CHILD CARE HOME	FACILITY NUMBER: 485407546
	VISIT DATE: 09/08/2022

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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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2022 04:26 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: NAEBKHEL, SURYA FAMILY CHILD CARE HOME	FACILITY NUMBER: 485407546
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the Licensee statement and Licensee not furnishing evidence to prove that at least one disaster drill was conducted within six months. 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: 09/22/2022
	Plan of Correction
1 2 3 4	Licensee stated she would conduct an emergency disaster drill and submit evidence to prove that a drill was conducted by thePOC due date. The Licensee stated she intends to submit her POC by 09/22/22 via mail, email or fax.

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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2022 04:26 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: NAEBKHEL, SURYA FAMILY CHILD CARE HOME	FACILITY NUMBER: 485407546
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

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 five children's (C1-C5) records reviewed at 1:00pm which did not contain Immunization Record (IR) for C1, C2 & C4. 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: 09/22/2022
	Plan of Correction
1 2 3 4	Licensee stated she would request and obtain immunization records from parents from C1, C2 & C4, and the Licensee would submit C1, C2 & C4's immunization records to the department by 09/22/22 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 five children's (C1-C5) records reviewed at 1:00pm which did not contain transcribed CDPH 286 for C1, C2 & C4. 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: 09/22/2022
	Plan of Correction
1 2 3 4	Licensee stated she would submit C1, C2 & C4's Immunization record onto the blue CDPH 286 and she would submit the transcribed forms to the Department by 09/22/22. 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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2022 04:26 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: NAEBKHEL, SURYA FAMILY CHILD CARE HOME	FACILITY NUMBER: 485407546
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the Licensee not furnishing evidence to prove that 15-minute checks had/were conducted while C2 & C4 napped. 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: 09/22/2022
	Plan of Correction
1 2 3 4	Licensee stated she would document at least three days worth of 15-minute checks on a Sleep Log for C2 & C4, and Licensee would submit evidence to prove she initiated 15-minutes for C2 & C4, and the evidence would be submitted by 09/22/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

Type B

Section Cited

CCR

102417(g)(3)

(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
1 2 3 4	Based on LPA's observation of a child safety gate installed at the bottom of the staircase, however; the gate did not securely barricade the staircase. 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: 09/22/2022
	Plan of Correction
1 2 3 4	The Licensee stated she would change another child safety gate and ensured the staircase was securely barricaded, and Licensee would submit a video illustrating the gate securely barricading the staircase.

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: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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