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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493007136
Report Date: 06/01/2022
Date Signed: 06/01/2022 11:21:06 AM


Document Has Been Signed on 06/01/2022 11:21 AM - 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:ROSE, CAMILLA FCCHFACILITY NUMBER:
493007136
ADMINISTRATOR:ROSE, CAMILLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 225-4520
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:14CENSUS: 7DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Camilla Rose, LicenseeTIME COMPLETED:
11:35 AM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Kevin O'Connell.
A review of staff records on 6/01/2022 indicates that all other facility staff or other individuals who require caregiver background checks have received 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, 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. There are currently two adults living in the home.
During today’s inspection the home and grounds were toured.
The licensee and her assistant were supervising seven preschool children. The facility’s operating hours are 07:30am to 05:30pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home were made inaccessible by door handle covers and locks. The back yard is used for outdoor play and is completely fenced.
The home was observed to be 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’s pediatric CPR and First Aid certifications were reviewed and expired on April, 2023. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children.
The licensee stated there are no firearms or ammunition stored on the premises and none were observed. The LPA observed a working smoke detector & carbon monoxide detector and fire extinguisher, rated at least 2A10BC in the home. The fireplace was barricaded with plywood.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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: ROSE, CAMILLA FCCH
FACILITY NUMBER: 493007136
VISIT DATE: 06/01/2022
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Poisons are key locked in the backyard shed. Licensee states that there are no pools, spas, water features and none were observed.
Eight child's record was reviewed at 10:25am during today's inspection. Two staff records were reviewed at 10:15am. The Mandated Reporter Training certificates for the Licensee and her assistant were expired.
LPA reviewed infant safe sleep logs and the new infant safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep web page 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. Licensee is not providing any IMS at this time. 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: 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 Camilla Rose. See LIC 9099d for Title 22 regulations cited today.

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: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/01/2022 11:21 AM - 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: ROSE, CAMILLA FCCH
FACILITY NUMBER: 493007136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

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
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Based on record review and Licensee's admission that her and her assistant's Mandated Reporter Training certificates have expired, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Complete trainings by 6/15/22 and send copies of completed certificates to CCL by 6/15/22.
kevin.oconnell@dss.ca.gov
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: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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