<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543909967
Report Date: 07/12/2021
Date Signed: 07/12/2021 12:33:48 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:PERGESON, CHELSIE FAMILY CHILD CAREFACILITY NUMBER:
543909967
ADMINISTRATOR:PERGESON, CHELSIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 789-7671
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:14CENSUS: 10DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chelsie PergesonTIME COMPLETED:
12:45 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
On 7/12/2021, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced annual inspection and met with Licensee, Chelsie Pergeson. Assistant, Eire Boswell was also present. A tour of the home was conducted, and a census was taken.
Days and hours of operation are Monday through Friday 7:30 AM to 5:30 PM and other hours as arranged.
Current facility sketch reviewed, and Licensee confirmed the day care room, which is a permitted, converted garage, with a restroom and the fenced backyard is accessible to children. The day care room can be accessed through a front door located to the left of the home. There were no stairs in the home. Safe toys and play equipment were observed. Licensee had a working telephone and the above telephone number was verified.
LPA did not observe any poisons in the home. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate cooling/heating and ventilation for safety and comfort. Licensee has 1 small dog that was inaccessible to children. The dog is kept inside the Licensee's home and not in the day-care room. Licensee is aware of child safety around pets and accepts responsibility for any action taken by pets. The outdoor play area in the backyard is fenced and there are no hazards to day care children. Licensee ensures that children in care are supervised at all times. There were no swimming pools, bodies of water, or firearms on the premises.
There are currently 4 infants in care. LPA discussed Safe Sleep Regulations with Licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping. There are no objects hanging above or attached to the crib or play yard. Infants in care are not swaddled. Infants can be visually observed.

(Continued on LIC809-C)
SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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: PERGESON, CHELSIE FAMILY CHILD CARE
FACILITY NUMBER: 543909967
VISIT DATE: 07/12/2021
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
26
27
28
29
30
31
32
A sample of children’s records contained all emergency information specified by regulation. There were no excluded individuals present at this home. All adults who reside or work in the home had a criminal record clearance or exemption. A review of records indicated Licensee has proof of required immunization; Pertussis, Measles, and a written declaration declining the Influenza shot. Licensee's Mandated Reporter Training (MRT) certificate expired on 11/17/2020. Licensee was unable to provide evidence of renewed MRT. Licensee's pediatric CPR and First Aid expired on 11/28/2020.
Adequate supervision was being provided during this inspection and capacity as specified on the license was being maintained. Staff-child ratios were maintained.
Incidental Medical Services (IMS) are not currently provided. Licensee is aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA information line at (800) 514-0301 (voice), (800) 514-0383 (TDD), and website link: https://www.ada.gov/childqanda.htm. http://www.ada.gov/childqanda.htm

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms, and Regulations.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencies were found (see the attached page, LIC809D):

Exit interview was conducted with Licensee. Licensee was provided a copy of the Facility Evaluation Report (LIC 809), Appeal Rights, and the Notice of Site Visit form (LIC 9213).

The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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: PERGESON, CHELSIE FAMILY CHILD CARE
FACILITY NUMBER: 543909967
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2021
Section Cited

1
2
3
4
5
6
7
EMPLOYEE & VOLUNTEER IMMUNIZATIONS ; Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination
8
9
10
11
12
13
14
between August 1 and December 1 of each year. This requirement was not met as evidenced by record review today. There was no documentation of immunizations for Licensee's Assistant who was present today. This poses a potential Health, Safety, & Personal Rights risk to children in care.
8
9
10
11
12
13
14
Type B
07/20/2021
Section Cited

1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS- The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
8
9
10
11
12
13
14
This requirement was not met as evidenced by record review today. Licensee First Aid/CPR cert. expired on 11/28/2020. This poses a potential Health, Safety, & Personal Rights risk to children in care.
8
9
10
11
12
13
14
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 FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3