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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002629
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:20:46 PM

Document Has Been Signed on 09/05/2024 01:20 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STEPPING STONES CCFFACILITY NUMBER:
045002629
ADMINISTRATOR/
DIRECTOR:		KUSSEROW-FRAZIER, ANNETTEFACILITY TYPE:
735
ADDRESS:215 VALLEY VIEW DRTELEPHONE:
(530) 534-4464
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: 3DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Annette Frazer - licenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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09/05/2024 9:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee/ administrator Annette Frazier and explained the purpose of the visit.

LPA and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Administrator certificate is current.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area in good repair with some clutter. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in May 2024. Smoke detectors are all operational. There are no pools/bodies of water are on premises. Last disaster drill was conducted on July 02, 2024 which was a fire evacuation due to the Thompson Fire. The facility has been conducting fire drills monthly and disaster drill quarterly..

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629
VISIT DATE: 09/05/2024
NARRATIVE
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The following deficiencies are being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22).

LPA observed debris in the back yard to include wood from a fence that has been demolished and replaced, and yard debris. LPA observed boxes and household materials stacked on the back deck. Licensee shall remove all of these items from the facility premises.

LPA observed child locks on cupboards that contain cleaning supplies and laundry detergent. Licensee will replace the child locks with keyed or combination padlocks.

LPA reviewed 5 staff files and 1 of 5 files did not have fingerprint clearance. This staff requires a criminal record exemption.

LPA reviewed 5 staff files TB clearance missing from 2 of 5 staff files.

LPA reviewed 5 staff files. 2 of 5 staff do not have current first aid certificates on file.

Appeal rights were provided, and an exit interview conducted, a copy of the report was provided to licensee / administrator Annette Frazier.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/05/2024 01:20 PM - It Cannot Be Edited


Created By: Rebecca Knight On 09/05/2024 at 12:18 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed child locks on cupboards that contain cleaning supplies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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 Licensee will replace the child locks with keyed or combination padlocks. Licensee shall submit photographs to LPA as proof of correction.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee shall obtain TB clearance for the 2 staff and submit clearaces to LPA as proof of correction.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2024 01:20 PM - It Cannot Be Edited


Created By: Rebecca Knight On 09/05/2024 at 12:18 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 5 staff records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee shall submit proof of exemption and/or fingerprint clearance to LPA as proof of correction. Licensee shall contact LPA if they require additional time to complete.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record revew the licensee did not comply with the section cited above in 2 of 5 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee shall submit first aid certificates for 2 of 5 staff to LPA as proof of correction.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


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Document Has Been Signed on 09/05/2024 01:20 PM - It Cannot Be Edited


Created By: Rebecca Knight On 09/05/2024 at 12:52 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed debris in the back yard to include wood form a fence that has been demolished and replaced, and yard debris. LPA observed boxes and household materials stacked on the back deck which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Licensee shall remove all of these items from the facility premises. Licensee shall submit photographs to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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