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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490170634
Report Date: 02/14/2023
Date Signed: 02/14/2023 04:35:04 PM


Document Has Been Signed on 02/14/2023 04:35 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:MAZZA, PAMELA FAMILY CHILD CARE HOMEFACILITY NUMBER:
490170634
ADMINISTRATOR:MAZZA, PAMELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 539-7461
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:12CENSUS: 2DATE:
02/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Pamela "Pam" MazzaTIME COMPLETED:
04:45 PM
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A Case Management inspection was conducted by Licensing Program Analyst (LPA) Amy Strother due to potential physical plant hazards reported to the Department on 02/02/23. LPA met with Licensee, Pam Mazza (L1). During today’s inspection, LPA toured the facility, requested records and conducted an interview with L1.

During the tour of the home, LPA observed a fire extinguisher rated at least 2A10BC located on the wall of the garage. LPA observed a working carbon monoxide detector in the home. LPA observed a working smoke detector in each of the three bedrooms.

During an interview with L1, LPA asked L1 if she had conducted and recorded a fire drill with the children in the last 6 months. At 12:12pm L1 stated that she has not completed a drill in the last 6 months. LPA requested to review L1's current Pediatric First Aid/CPR certificate. At 12:30pm L1 stated that she does not have a current First Aid/CPR certificate. LPA requested to review the following for forms, LIC9040 Facility Roster, LIC700 Identification and Emergency Information for each child present, Child 1 (C1) and Child 2 (C2) and LIC627 Consent for Emergency Medical Treatment for C1 and C2, L1 stated that she did not have any of those forms. L1 handed a folder to LPA Strother stating that what LPA is looking for may be in there. LPA did not observe any of the completed forms mentioned above in the folder. L1 was able to provide LPA with the names and dates of birth of C1 and C2 by referencing hand written notes taped to the kitchen wall, near the telephone. L1 stated during the tour of the home that she has one infant, Child 3 (C3) age 4 months, that comes to care about 3 days a week, but was not able to provide LPA with C3's date of birth when requested. LPA asked L1 if she was familiar with the safe sleep regulations and requirements. L1 stated that she was not familiar with any safe sleep regulations or requirements. LPA asked L1 if she has a LIC9227 Individual Infant Sleeping Plan and a record/log of visual checks documenting C3's name, the date and the time of each 15 minute visual check during times when C3 is asleep in care. L1 stated that she does not have form LIC9227 or a sleep log for C3. During today's visit, LPA reviewed the safe sleep regulations and requirements with L1, providing L1 with a copy of form LIC9227 and a sample sleep log.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MAZZA, PAMELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 490170634
VISIT DATE: 02/14/2023
NARRATIVE
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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, Pamela Mazza.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/14/2023 04:35 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: MAZZA, PAMELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 490170634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited

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(g)The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be 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.
This requirement is not met as evidenced by:
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Licensee will conduct a fire drill or disaster drill with the children in care and document the drill. Licensee will write out a procedure for ensuring that she will conduct a drill every 6 months and provide LPA with a copy of L1's procedure by 03/16/23 mailing to LPA Strother at the Santa Rosa Regional Office.
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Based on interview with L1 and a record review, L1 have not conducted a fire drill conducted in the past 6 months, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/16/2023
Section Cited

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(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.
This requirement is not met as evidenced by:
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Licensee will enrolled in a EMSA approved Pediatric First Aid/CPR course and provide proof of enrollment to LPA by 03/16/23 and provide a certificate of completion to LPA once the course is complete.
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Based on interview with L1 at 12:30pm, the licensee did not comply with the section cited above and does not possess a current pediatric first aid/CPR certificate, which poses a potential health, safety or personal rights risk to persons in care.
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/14/2023 04:35 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: MAZZA, PAMELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 490170634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.



This requirement is not met as evidenced by:
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Licensee stated that she will use form LIC9040 adding the information for each child she currently has enrolled and continue to add any additional children she enrolls. Licensee will provide a copy of the current roster to LPA Strother by 03/16/23 by mail: CCLD
1450 Neotomas Ave. Suite 100, Santa Rosa, CA 95405
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Based on interview with Licensee, Licensee does not keep a roster of children enrolled in her family child care home which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/16/2023
Section Cited

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(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
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Licensee stated that she will have the parents of C1 and C2, as well as any other children enrolled complete forms LIC700 and LIC627. Licensee will provide copies of C1 and C2's completed LIC700 and LIC627 to LPA Strother by 03/16/23.
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Based on interview, licensee was not able to produce a file for two out of two children present. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/14/2023 04:35 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: MAZZA, PAMELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 490170634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited

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102425(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.

This requirement is not met as evidenced by:
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Licensee stated that she will ensure that parent of C3 and parent(s) of any infants under 12 months enrolled in the future will complete the LIC 9227 to be kept in the infant's file.
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Based on interview, Licensee stated that she has one infant (C3) enrolled in care that is age 4 months and does not have form LIC9227 on file for C3 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/16/2023
Section Cited

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The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.

This requirement is not met as evidenced by:
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Licensee will begin to conduct sleep checks when C3 is in care, visually checking on C3 every 15 minutes, logging C3's name, date and time of each check.
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Based on interview Licensee stated that she has one infant (C3) enrolled in care that is age 4 months and does keep a sleep log for C3 which poses a potential health, safety or personal rights risk to persons in care.
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5