543909967-7-11-2019-04-CC-TMAZ-BDYPCP-20190711111216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 543909967
Report Date: 07/11/2019
Date Signed: 07/11/2019 11:12:24 AM

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:	PERGESON, CHELSIE FAMILY CHILD CARE		FACILITY NUMBER:	543909967
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	07/11/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Chelsie Pergeson		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced Annual inspection and met with Licensee Chelsie Pergeson. Also present was Assistant Kaitlyn Hinkley. The working telephone number was verified. Postings such as facility license, Emergency Disaster Plan, Earthquake preparedness checklist, and Notification of Parent’s Rights are posted at the front entrance of the day-care room wall.

LPA Marquez conducted a tour of the day-care room, inside and outside. Day care children only have access to the day care room, which is a permitted, converted garage. The day care room can be accessed through a front door located to the left of the home. A working fire extinguisher is present. The Smoke detector/carbon monoxide indicator were tested and observed to be operational. Adequate supervision is being provided during this inspection.

The backyard is off limits at this time due to Licensee is remodeling with cement and installing a new fence. Licensee has a small dog that is kept in her home; licensee is aware of the safety of children around animals. There are no "bodies of water" or firearms in this home.

Capacity as specified on the license is being maintained. Licensee has a current roster of the children. A random sample of Children’s files were reviewed for documentation of immunizations. Staff files were reviewed for record of immunizations; pertussis, measles and influenza for herself and staff. Licensee has provided parents with a copy of the Family Child Care Home Notification of Parent's Right (LIC995A). The most recent fire drill was conducted on 11/6/2018. All adults who reside or work in the home have a criminal record clearance and/or exemption. Pediatric CPR/First Aid is current and expires 11/17/2020. Mandated Reporter training AB 1207 is current and expires 11/28/2020. 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 advance notice.

Days and hours of operation are Monday – Friday; 7:30 AM – 5:30 PM.

(Continued on LIC809-C)

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa Marquez	TELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PERGESON, CHELSIE FAMILY CHILD CARE	FACILITY NUMBER: 543909967
	VISIT DATE: 07/11/2019

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LPA & Licensee discussed the Community Care Licensing (CCL) website, newly proposed Safe Sleep regulations, Mandated Reporter Training and the new additions to the website that include the Provider Information Notifications (PIN), including the Quarterly Updates that informs licensees of new legislation and regulations.

LPA discussed Incidental Medical Services (IMS). For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for FCCH Section 102417.
No IMS are being provided at this time.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency was observed on the attached LIC809-D.
A copy of Licensee Appeal Rights was provided to Chelsie Pergeson today.

THE LICENSING FORM LIC9213 NOTICE OF SITE VISIT IS REQUIRED TO BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa Marquez	TELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PERGESON, CHELSIE FAMILY CHILD CARE	FACILITY NUMBER: 543909967
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/25/2019 Section Cited CCR 102417(g)(9)(A)(1)	1 2 3 4 5 6 7	OPERATION OF A FAMILY CARE HOME - OPERATION OF FAMILY CHILD CARE HOME - Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill.	1 2 3 4 5 6 7	Licensee stated she will conduct and document a fire drill every 6 months moving forward. Licensee will send evidence of a fire drill to the Fresno CCL office by July 25, 2019.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by record review. Licensee documented and conducted their last fire drill on 11/06/2018. This poses a potential Health, Safety, & Personal Rights risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Susie Fanning	TELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa Marquez	TELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2019

LIC809 (FAS) - (06/04)

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