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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500311956
Report Date: 01/21/2020
Date Signed: 01/21/2020 03:12:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CHAPMAN, CINDYFACILITY NUMBER:
500311956
ADMINISTRATOR:CHAPMAN, CINDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 531-0838
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY:14CENSUS: 3DATE:
01/21/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cindy ChapmanTIME COMPLETED:
03:30 PM
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On 01/21/2020, Licensing Program Analyst (LPA) Candis Rodriguez conducted an unannounced annual inspection. LPA met with Licensee Cindy Chapman and took a tour of the facility. LPA took a census and observed three (3) children. Rooms accessible to the children are the living room, kitchen, dining room, and hallway bathroom. Hours of operation are 6:00AM to 6:00PM, Monday through Friday.

Two dogs were observed in the home. There is a frog pond in the backyard which is fenced according to regulations. There is a working fire extinguisher, smoke detectors, and carbon monoxide detector. The home has adequate heating and ventilation for safety and comfort. There are no stairs in the home.

There is a working telephone and number was verified. Adequate supervision is being provided during this inspection. Licensee stated the back yard is off limits to children in care. Capacity as specified on the license is being maintained.

Upon review of facility files, LPA observed Child #1 and Child #2 are both missing their immunization documentation and Consent for Emergency Medical Treatment (LIC 627) required forms. LPA also observed Child #3 is missing the Consent for Emergency Medical Treatment, proof of immunizations, and Parents’ Rights form (LIC 995A). Licensee has a current roster of the children. Licensee maintains documentation of immunizations for herself.

The last fire drill was conducted in January 2020.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: CHAPMAN, CINDY
FACILITY NUMBER: 500311956
VISIT DATE: 01/21/2020
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Licensee is aware that children are never to be left in parked vehicles.

Pediatric CPR/First Aid are current expiring in June of 2021. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advanced notice.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if she provides these services. The following information regarding Americans with Disability Act (ADA) was provided: US Department of Justice toll free ADA Information line at (800) 514-0301(voice) and (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm for Commonly Asked Questions about Child Care Centers and the ADA.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINS), Quarterly Updates, Mandated Reporter Training, Safe Sleep in Child Care, Forms and Regulations.

Per Chapter 1, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found: (see LIC809-D). Site Visit Notice posted on the parent board. Exit interview was conducted with Licensee Cindy Chapman.
Licensee was provided a copy of appeal rights.

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: CHAPMAN, CINDY
FACILITY NUMBER: 500311956
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
Section Cited

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An emergency information card shall be maintained for each child and shall include ... and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement was not met as evidenced by:
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Based on record review, licensee did not ensure all children had completed required forms in their files. This poses a potential risk to the health, safety and personal rights of children 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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2020
LIC809 (FAS) - (06/04)
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