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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624237
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:03:50 PM

Document Has Been Signed on 01/17/2023 02:03 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CARMONA, JESSICAFACILITY NUMBER:
293624237
ADMINISTRATOR:CARMONA, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 344-3938
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jessica CarmonaTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Matthew Gallo and Jennifer Velasco met with Licensee Jessica Carmona for the purpose of an unannounced required 1-year inspection. Licensee states no other adults are present in the home. At 12:20pm, LPA observed a total census of 7 children, including 2 infants and 5 preschoolers.

Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include living room, all upstairs, garage, cellar, and all outbuildings. Licensee acknowledged that children must never enter these areas. LPAs observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home. LPA did not observe bodies of water at the facility. Toxic and hazardous items are inaccessible to children. The stairs in the home are properly barricaded. Outdoor play space is properly fenced.

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.

At 12:50pm, LPA began to review Children’s files and other documentation. A current roster is being maintained. Licensee's fire and disaster drills are conducted and documented. Preventative health training, current pediatric CPR and First Aid certification was verified for Licensee (exp 2/224) and Mandated Reporter Training (AB 1207) for the Licensee was also verified (2/24).

15-minute sleep logs were missing, and LPA discussed proper Safe Sleep practice.

(Report continues LIC809-C)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CARMONA, JESSICA
FACILITY NUMBER: 293624237
VISIT DATE: 01/17/2023
NARRATIVE
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LPA further referenced 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

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided an updated Plan of Operation that includes 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]

One Title 22 deficiency is cited on the subsequent pages of this report.

Exit interview conducted and report was reviewed with the licensee Jessica Carmona.

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.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/17/2023 02:03 PM - It Cannot Be Edited


Created By: Matthew Gallo On 01/17/2023 at 01:25 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: CARMONA, JESSICA
FACILITY NUMBER: 293624237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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:Keven Peters
LICENSING EVALUATOR NAME:Matthew Gallo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/17/2023 02:03 PM - It Cannot Be Edited


Created By: Matthew Gallo On 01/17/2023 at 01:55 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: CARMONA, JESSICA
FACILITY NUMBER: 293624237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 2 cases which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Licensee will email LPA Gallo with picture of sleep log
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Keven Peters
LICENSING EVALUATOR NAME:Matthew Gallo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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