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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423363
Report Date: 06/14/2023
Date Signed: 06/14/2023 05:16:08 PM

Document Has Been Signed on 06/14/2023 05:16 PM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:YOUNGBLOOD, DESIREEFACILITY NUMBER:
013423363
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Desiree Youngblood TIME COMPLETED:
05:25 PM
NARRATIVE
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On June 14, 2023 at 12:45pm Licensing Program Analyst (LPA) Indira Loza arrived and met with the Licensee Desiree Youngblood for the purpose of conducting an unannounced 1-year annual inspection. Present for today’s inspection were the Licensee, one assistants and 4 infants in care. The facility is in ratio today.Hours of operation are Monday - Friday 7:30am to 5:30pm.

The facility is a single-story home with two bedrooms; one bathroom; a living room (day care area); dining room; and kitchen. The home has heating and ventilation for safety and comfort.

ON LIMIT AREAS: Living room and kitchen.



OFF LIMIT AREAS: two bedrooms and bathroom. The off-limit areas will be inaccessible by child gates, closed and/or locked doors and adult supervision.

ISOLATION AREA will be on the couch in the living room. All required postings are present.


The home has a fully charged 2A10BC fire extinguisher in the closet next to the living room, smoke and carbon monoxide detectors, and a working telephone. Fire drills are conducted at least once every 6 months, the last drill was completed in May 9, 2023. Licensee has ample age-appropriate toys and learning materials inside and outside the home. Drop-down cribs are not allowed at the day-care facility. Toxins, medicines, and hazardous items were inaccessible during today's inspection. The Licensee takes the children to the local park for outdoor play. LPA reviewed children's files which were found to be complete. The Personnel files were missing several documents. The facility roster was reviewed, and a copy obtained.

***********************************Report Continues on LIC 809-C*******************************

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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Document Has Been Signed on 06/14/2023 05:16 PM - It Cannot Be Edited


Created By: Indira Loza On 06/14/2023 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: YOUNGBLOOD, DESIREE
FACILITY NUMBER: 013423363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 infants did not have the 15 minute checks documented a, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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4
The Licensee shall email the LPA a copy of 5 days of sleeping records, no later than July 14, 2023.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview record review, the licensee did not comply with the section cited above in one out of two staff did not have their immunizations on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Licensee shall email the current immunizations for the Assistant no later than July 14, 2023.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 05:16 PM - It Cannot Be Edited


Created By: Indira Loza On 06/14/2023 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: YOUNGBLOOD, DESIREE
FACILITY NUMBER: 013423363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in one out of two staff did not have a complete file, which was missing, criminal record statement, employee rights, and immunizations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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4
The Licensee shall email a copy of her Assistant's personnell file, no later than July 14, 2023.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above in one out of one infant under 12 months old did not have an LIC 9227 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Licensee shall email a complete LIC 9227 no later than July 14, 2023.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: YOUNGBLOOD, DESIREE
FACILITY NUMBER: 013423363
VISIT DATE: 06/14/2023
NARRATIVE
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Mandated Reporter certificates for the Licensee and Assistant were current. Licensee was reminded that CPR/1st Aide and Mandated Reporter is to be renewed every two years.


Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02. 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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.

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/inspection-process.

There were four deficiencies issued during today's visit. The report will remain on file for three years.

************************************Report Continues on LIC 809-C************************************

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: YOUNGBLOOD, DESIREE
FACILITY NUMBER: 013423363
VISIT DATE: 06/14/2023
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See LIC 809-D (2) for the deficiencies.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the Licensee Desiree Youngblood.

Report and Appeal Rights were provided.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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