493002923-8-8-2024-01-CC-RMAL-D7XSEV-20240808134921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493002923
Report Date: 08/08/2024
Date Signed: 08/08/2024 01:49:44 PM

Document Has Been Signed on 08/08/2024 01:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MACHADO, CYNTHIA FAMILY CHILD CARE HOME		FACILITY NUMBER:	493002923
ADMINISTRATOR:	MACHADO, CYNTHIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 794-8444
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY:	14	CENSUS: 14	DATE:	08/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Cynthia Machado		TIME COMPLETED:	01:59 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 Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 8/8/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. During today’s inspection the home and grounds were toured. The Licensee was supervising 14 children. At 9:15 AM LPA observed a 15th child, child 4 (C4) dropped off at the facility. No children were observed left in any parked vehicles. The facility’s operating hours are 7:30 AM to 5:30 PM, Mon–Fri. The floor plan submitted by the licensee was reviewed. The on-limits areas of the home are the living room, the kitchen, the 1st floor bedroom the 3rd floor bathroom, and the backyard. The off-limits areas of the home are the 1st floor living area, the 1st floor hall, the second floor office, the front yard, the garage, and the third floor bedrooms, and were made inaccessible by door locks and child gates. The home was at a comfortable indoor temperature. The children in care have access to age-appropriate toys and equipment. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification was current and expires in August 2025. LPA observed a working smoke alarm, carbon monoxide detector, and a fully charged fire extinguisher rated at least 2A10BC. LPA observed that the earthquake preparedness checklist was incomplete and not posted in a public place. The licensee stated that poisons are not stored in the home and none were observed by the LPA. Continue to LIC 809-C.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
	VISIT DATE: 08/08/2024

NARRATIVE

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The regulation that poisons are to be locked using a key or combination lock was reviewed. The Licensee stated that there are firearms in the home which were observed to be locked in a safe. Licensee opened the safe which revealed that ammunition was stored with the firearms in the safe. The Licensee's husband (A1) moved the ammunition to a separate safe during the visit. LPA observed no bodies of water in the facility. The Licensee conducted an emergency disaster drill on 6/14/24. LPA observed child 2 (C2) sleeping in a play pen on his stomach. The facility roster of the children in care was reviewed which revealed that C2 and child 4 (C4) were not recorded on the roster. LPA reviewed staff and personnel records at 1:53 PM which revealed that the Licensee and staff 1 (S1) did not possess current mandated reporter training certificates and S1 did not possess an immunization record. LPA reviewed five children's records (C1-C5) at 1:59 PM which revealed that C4 and C5 did not possess verification of enrollment in school, the licensee did not record the 15 minute sleep checks for child 2 (C2) for 8/8/24, and C2 did not possess a record of immunizations, an emergency information card, a signed Notification of Parent's Rights, or a LIC9227 Individual Infant Sleeping Plan.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Continue to LIC 809-C.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
	VISIT DATE: 08/08/2024

NARRATIVE

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On this date, 08/08/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. Exit interview conducted and report was reviewed with Licensee Cynthia Machado. 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.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)(C)

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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (C) Ammunition shall be stored and locked separately from firearms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, firearms and ammunition are locked in a safe which, while inaccesible to children, were stored together which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	LPA observed Licensee's husband (A1) move the ammunition into a separate safe used only for storing ammunition.

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not record 15 minute sleep checks for child 2 (C2) for which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee immediately recorded the missing sleep checks and signed a statement attesting her understanding of the infant safe sleep regualtions.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,the licensee and staff 1 (S1) did not possess current mandated reporter training certificates which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain a current mandated reporter training certificate for herself and S1 and send a copy to LPA by email at robert.maciel@dss.ca.gov.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not possess any record of immunizations for staff 1 (S1) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain the immunization record for S1 and send a copy to LPA by email at robert.maciel@dss.ca.gov.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, child 2 (C2) did not possess record of immunizations which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain record of C2's immunizations and send a copy to LPA by email at robert.maciel@dss.ca.gov

Type B

Section Cited

CCR

102421(b)

Child's Records

(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, child 2 (C2) did not possess an emergency information card which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain a complete emergency information card and send a copy to LPA by email at robert.maciel@dss.ca.gov

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the facility roster of children in care did not contain record of child 2 (C2) and child 4 (C4) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated that she would add C2 and C4's information to the roster and send a picture of it to LPA by email at robert.maciel@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,child 2 (C2) did not possess a copy of the signed Notification of Parent's Rights which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain the signed Notification of Parent's Rights for C2 and send a copy to LPA by email at robert.maciel@dss.ca.gov.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2024 01:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MACHADO, CYNTHIA FAMILY CHILD CARE HOME	FACILITY NUMBER: 493002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, child 2 (C2) did not possess a complete LIC9227 Individual Infant Sleeping Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain a complete LIC9227 Individual Infant Sleeping Plan and send a copy to LPA by email at robert.maciel@dss.ca.gov.

Type B

Section Cited

CCR

102416.5(a)

Staffing Ratio and Capacity

(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, at 9:15 AM, child 4 (C4) was dropped off at the home bringing the total number of children to 15 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee called called the parent of C4 who picked her up. Additionally, Licensee signed a written statement attesting her understanding of the regulations pertaining to the amount of children allowed to be in care at one time.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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