493009773-7-13-2021-01-CC-ASTR-C4VW3T-20210713165628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 07/13/2021
Date Signed: 07/13/2021 04:56:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	PEREZ, EMILIO FCCH		FACILITY NUMBER:	493009773
ADMINISTRATOR:	EMILIO PEREZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 230-1631
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	14	CENSUS: 14	DATE:	07/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Emilio Perez		TIME COMPLETED:	05:15 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-1 year inspection was made to the facility by Licensing Program Analyst (LPA) Amy Strother. LPA Strother met with Licensee Emilio Perez (L1). A review of staff records on 07/13/21 indicates that all facility staff or other individuals who require caregiver background checks have not received criminal record and child abuse index clearances or exemptions. Two staff, Staff 1 and Staff 2 (S1 and S2) were present working in the facility that were not listed on the Facility Clearance Roster. L1 stated at 2:19pm that S1 and S2 have not yet completed the required LiveScan process. L1 stated that S1 has worked at the facility since May 2021 and S2 has been employed since June 2021. There is currently 1 adult, L1 living in the home. During today’s inspection the home and grounds were toured. The licensee and 3 assistants (Staff 1 - Staff 3) were supervising 6 school-age children, 5 preschool children and 3 infants, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are Monday-Saturday 6:30am to 8:30pm. The floor plan submitted by the licensee was reviewed and verified. The garage and the entire upper floor of the home is off limits to the children. The garage has been made of limits with a door lock and the upper level of the home has been made inaccessible by a child safety gate at the bottom of the staircase. The home was 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 has current pediatric CPR and First Aid certification, which expires on 07/2023 and current mandated reporter training, which expires 7/2023. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The licensee stated no poisons are located on the property, and none were observed during today's inspection. The home has two fireplaces downstairs, each fireplace is securely screened or barricaded. There is a working smoke detector, carbon monoxide, and 2A10BC fire extinguisher. L1 stated there are no firearms or weapons stored on site and none were observed during today's inspection. The room used for non-mobile infants, included 2 play yards, one for each infant under 12 months of age in care. LPA reviewed the safe sleep log with the required documentation and reviewed form LIC9227 for each infant under 12 months of age. The children use the back yard as the outdoor play area and it is fully fenced. Continue on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PEREZ, EMILIO FCCH	FACILITY NUMBER: 493009773
	VISIT DATE: 07/13/2021

NARRATIVE

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Fourteen children's (C1 - C14) records were reviewed at 1:35PM; required emergency information was observed to be on file. The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

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

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

An exit interview was conducted and Plans of corrections were reviewed and developed with the Licensee. Appeal Rights were provided and discussed with, Emilio Perez whose signature on this form confirm receipt of these documents.

Notice of Site Visit shall be posted for 30 days from today's visit.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PEREZ, EMILIO FCCH	FACILITY NUMBER: 493009773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/14/2021 Section Cited	1 2 3 4 5 6 7	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted and fingerprint record review, the licensee did not ensure A1 and A2 were fingerprint background cleared or have an approved criminal record exemption prior to employment or presence in the home, which poses an immediate health and safety risk to children in care.	8 9 10 11 12 13 14	L1 provided LPA with a written statement on 07/13/21 acknowledging that all adults living or working in the home will have a criminal record clearance prior to living or working at the facility.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

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