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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103910500
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:07:10 PM

Document Has Been Signed on 06/23/2022 12:07 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:SURRATT, KAREN FAMILY CHILD CAREFACILITY NUMBER:
103910500
ADMINISTRATOR:SURRATT, KARENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 512-9911
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 0DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karen SurrattTIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/23/2022 Licensing Program Analysts (LPAs) Stephanie Vega-Gonzalez and Caroline Harris, conducted an unannounced Annual Required Inspection and was met by Licensee, Karen Surratt. A census of zero was taken on today’s inspection. Days and hours of operation are Monday through Friday from 5:30am to 6:30pm.

Current facility sketch reviewed and Licensee confirmed that the kitchen, hallway bathroom, living room, day care room, and yard are used for providing care and are accessible to children. Facility sketch was updated during inspection. All other rooms are off-limits and made inaccessible by use of spinner safety knobs. There is no swimming pool or other bodies of water on the premises. There are no firearms and ammunition in the facility. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. Facility has a fireplace that is located in the living room and is made inaccessible and enclosed by fireplace gate. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. The home has working telephone service and LPA confirmed the phone number is (559) 512-9911. LPA observed to have one small dog, licensee understands that she takes responsibility for any actions taken from her pets. The outdoor play area in the backyard is fenced. Capacity as specified on the license is being maintained. Car seats are used for transportation purposes only and are not used for sleeping children. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles.

Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s Mandated Reporter Training was completed on 06/29/2021. Licensee’s pediatric CPR/First Aid expires on 01-23-2023. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

There are currently no infants in care.

(Continued on 809-C)

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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 06/23/2022 12:07 PM - It Cannot Be Edited


Created By: Stephanie Vega-Gonzalez On 06/23/2022 at 11:00 AM
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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SURRATT, KAREN FAMILY CHILD CARE
FACILITY NUMBER: 103910500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on record review, the licensee did not comply with the section cited above in today's inspection Licensee was not able to provide LPA recrods of immunization for the following individuals: Licensee Karen Surrat TDAP,MMR; Assistant Kasandra Harris TDAP,MMR, Influenza; Boyfriend Tyrone Smith TDAP,MMR, Influenza out of persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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Licensee has agreed to provide copies of recrods of immunizations for the following individuals: Licensee Karen Surrat TDAP,MMR; Assistant Kasandra Harris TDAP,MMR, Influenza; Boyfriend Tyrone Smith TDAP,MMR, Influenza on the POC deadline to LPA.
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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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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: SURRATT, KAREN FAMILY CHILD CARE
FACILITY NUMBER: 103910500
VISIT DATE: 06/23/2022
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Incidental Medical Services (IMS) are not currently being provided. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 understands that a IMS plan is required to be submitted to CCL office prior to providing IMS services.
Licensee Karen Surratt 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, 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 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. LPA provided information to licensee. Licensee understands that it is her responsibility to stay current with regulations.

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/process.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D). Licensee was provided a copy of appeal rights.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Karen Surratt.

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Stephanie Vega-Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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