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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313611330
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:19:32 PM

Document Has Been Signed on 05/17/2022 02:19 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NELSON, ELLENFACILITY NUMBER:
313611330
ADMINISTRATOR:NELSON, ELLENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 626-9570
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 11DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Ellen NelsonTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, Ellen Nelson, for the purpose of an unannounced required 1-year inspection. The licensee's husband adult daughter (assistant) were also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. At 1:10pm, LPA observed a total census of 10 napping children including 2 infants under 12 months, 8 preschool children, and 1 school age child..

At 1:30 p.m., 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 master bedroom and bathroom. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no stairs in the home Outdoor play space is 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. LPA reviewed children’s files and observed immunization records and emergency contact information. A current roster is being maintained and fire and disaster drills are documented. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires 4/8/2023, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 6/10/2023. (Report continues LIC809-C)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: NELSON, ELLEN
FACILITY NUMBER: 313611330
VISIT DATE: 05/17/2022
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LPA observed two play yards at the facility. Play yards were free of loose objects. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

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

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
Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information.

Title 22 Deficiency has been cited on the attached LIC 809-D. Appeal Rights given.

Exit interview conducted and report was reviewed with the licensee Ellen Nelson.
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.

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
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2022 02:19 PM - It Cannot Be Edited


Created By: Amanda Blesi On 05/17/2022 at 01:48 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: NELSON, ELLEN
FACILITY NUMBER: 313611330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 infant children ages 8 months did not have a sleep log check every 15 minutes whcih which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee states she is physically checking on the infants however she has not been keeping a log of the times and dates the infants are checked. LPA printed out the sleep regulations so licensee can review the requirements. To correct the deficiency, licensee shall submit a completed sleep log for the two infants in care. This shall be sent to LPA by correction date 5/24/22.
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 record review, the licensee did not comply with the section cited above in two out of two infants age 8 months did not have a form LIC 9227 in their children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee shall submit a completed form LIC 9227 for the two infants in care. This shall be sent to LPA by 5/24/22 to correct the deficiency.
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:Amanda Blesi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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