<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846004
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:56:27 PM

Document Has Been Signed on 10/13/2022 04:56 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:NOBLE FAMILY CHILD CAREFACILITY NUMBER:
334846004
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mercedes Noble, LicenseeTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On date and time listed, Licensing Program Analyst (LPA) Kay Turner and Licensing Program Manager (LPM) Aaron Ross arrived at the facility to conduct a required/annual inspection as part of a compliance review and capacity increase. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: Normal days and hours of operation are: Monday to Friday, 7:00am to 6:00pm OFF-LIMIT AREAS INCLUDE: there are no off limit areas.
The facility is not operating within the licensed capacity and appropriate ratios
· Appropriate supervision was not provided during this inspection

· A working telephone is present and current number on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.

· Fireplace is properly screened to prevent access by children

· All hazardous items are stored inaccessible to children

· Toxins are locked

· Weapons are not present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· This is a one story home

· Verification of control of property on file

· Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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 8
Document Has Been Signed on 10/13/2022 04:56 PM - It Cannot Be Edited


Created By: Karrene Turner On 10/13/2022 at 03:33 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above S1 does not have a valid criminal clearance. S1 reported of being employed at the facility for approximately 2 months, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of receipt of the livescan for S1 to the LPA by the POC due date. This violation results in a Civil Penalty in the amount of $500.
Type A
Section Cited
CCR
102416.5(b)(2)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as LPA and LPM observed a total of 6 infants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
1
2
3
4
Licensee agrees to come into agreement with Title 22 Regulation and provide proof of compliance to the LPA by the POC due date.
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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Turner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 10/13/2022 04:56 PM - It Cannot Be Edited


Created By: Karrene Turner On 10/13/2022 at 03:33 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

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 in the disaster plan is not posted to the parent board, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to post the disaster plan to the parents board and provide proof of posting to the LPA by the POC due date.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as S1 file did not contact the LIC 9052, Notice of Employee RIghts, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to have S1 complete the LIC 9052, Notice of Emplyee RIghts, and submit proof of completed document to the LPA by the POC due date.
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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Turner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/13/2022 04:56 PM - It Cannot Be Edited


Created By: Karrene Turner On 10/13/2022 at 03:33 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as C3 did not have record of immunizations in the file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of immunizations for C3 to the LPA by the POC due date.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the LIC 995A, Notification of Parent's Rights, were missing from the file of C3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit the completed LIC 995A, Notification of Parental Rights, for C3 to the LPA by the POC due date.
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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Turner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/13/2022 04:56 PM - It Cannot Be Edited


Created By: Karrene Turner On 10/13/2022 at 03:33 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the roster is incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to update and thoroughly complete the facility roster and submit proof to the LPA by the POC due date.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the affidavit, LIC 282 was in C3 file but incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of the completed LIC 282 to the LPA by the POC due date.
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:Aaron Ross
LICENSING EVALUATOR NAME:Karrene Turner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004
VISIT DATE: 10/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· Facility Sketch & Notification of Parent’s Rights poster are posted; Emergency Disaster Plan is not posted

· Mandated Reporter Training completed on 06/03/2022

· Pediatric CPR and First Aid Card expired 04/15/2022; CPR completed was not pediatric

· Health & Safety Certificate - completed 12/2020

· Fire clearance granted 09/29/2022

· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.

· Clean, safe and age appropriate toys

· Current roster on file but incomplete

· Documentation of fire and disaster drills on file – Last drill conducted on 09/22/2022

· Children’s records are incomplete

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 10/13/2022 indicate that all adults who require caregiver background checks have not received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at:

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004
VISIT DATE: 10/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 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: http://www.ada.gov/childqanda.htm

- 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.

- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

- To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at: https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: NOBLE FAMILY CHILD CARE
FACILITY NUMBER: 334846004
VISIT DATE: 10/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
See LIC809-D for cited deficiencies.

LPA Kay Turner informed licensee, Mercedes Noble, that this report dated 10/13/2022 documents 2 Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

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



Also, LPA Kay Turner informed the licensee, Mercedes Noble, to provide a copy of this licensing report dated 10/13/2022 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 Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The LICENSEE, Mercedes Noble, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee, Mercedes Noble.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8