045406496-10-12-2023-13-CC-JGID-CWJTPA-20231012145402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045406496
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:54:12 PM

Document Has Been Signed on 10/12/2023 02:54 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SOUTHWORTH, ASHTON FAMILY CHILD CARE HOME		FACILITY NUMBER:	045406496
ADMINISTRATOR:	SOUTHWORTH, ASHTON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 403-9468
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	David Southworth		TIME COMPLETED:	03:10 PM

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On 10/12/2023 at 1:20 p.m., an annual inspection was made to the facility by Licensing Program Analyst LPA, Julie Gifford and Erica Laird. At 1:29 p.m. the home was toured inside and outside. The facility representative was supervising 9 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:00 a.m.-5:30 p.m. Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are 3 bedrooms, 1 bathroom, and backyard were made inaccessible by lock and alarm. The children use the front yard as the outdoor play area and it is fully fenced. The licensee has a waiver on file for door locks, alarms, and the terms of the waiver are being met.

5 children's records were reviewed at 1:39 p.m. 2 staff records were reviewed at 1:40pm. There are currently 2 adults living in the home.

The following deficiencies were cited: LPA's observed one child with a blanket over their pack n' Play. One child was observed sleeping with a blanket in their pack n' play. (see LIC 809D):

LPA's Julie Gifford and Erica Laird informed facility representative David that this report dated 10/12/2023 documents 2 Type A citation(s) which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA's Julie Gifford and Erica Laird informed the facility representative to provide a copy of this licensing report dated 10/12/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Julie Gifford
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SOUTHWORTH, ASHTON FAMILY CHILD CARE HOME	FACILITY NUMBER: 045406496
	VISIT DATE: 10/12/2023

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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed facility representative 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Julie Gifford
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SOUTHWORTH, ASHTON FAMILY CHILD CARE HOME	FACILITY NUMBER: 045406496
	VISIT DATE: 10/12/2023

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Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, David Southworth, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the facility representative David Southworth.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Julie Gifford
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 02:54 PM - It Cannot Be Edited

Created By: Julie Gifford On 10/12/2023 at 02:39 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SOUTHWORTH, ASHTON FAMILY CHILD CARE HOME	FACILITY NUMBER: 045406496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Specifically, LPA's observed one child with a blanket in the pack n' play while sleeping.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Blanket was removed from pack n' play. Licensee to provide a written statement to CCL acknowledging understanding of safe sleep regulations. Safe Sleep regulations, Safe Sleep Q and A, and prohibited device sheet were provided to licensee.

Type A

Section Cited

CCR

102425(g)

Infant Safe Sleep

An infant’s head shall not be covered while sleeping. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Specifically, LPA's observed one child with a blanket draped over the pack n' play while sleeping.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Blanket was immediately removed from pack n' play. Licensee to provide a written statement to CCL acknowledging underdstanding of safe sleep regulations. Safe Sleep regulations, Safe Sleep Q and A, and prohibited device sheet were provided to licensee.

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:

Erin Virrueta

LICENSING EVALUATOR NAME:

Julie Gifford

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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