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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340305706
Report Date: 05/17/2021
Date Signed: 06/17/2021 03:43:00 PM

Document Has Been Signed on 06/17/2021 03:43 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:FOREVER YOUNG INFANT CARE CENTERFACILITY NUMBER:
340305706
ADMINISTRATOR:TYSON, SELINAFACILITY TYPE:
830
ADDRESS:1209 P STREET #12TELEPHONE:
(916) 446-4246
CITY:SACRAMENTOSTATE: CAZIP CODE:
95814
CAPACITY: 20TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
05/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carleton BebinsTIME COMPLETED:
09:00 AM
NARRATIVE
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**NOTE: This is an Amended Report**

Due to Covid-19 and DPH guidelines on social distancing, a Tele-visit via FaceTime was conducted.

On 5/18/2021, Licensing Program Analyst (LPA) Alize Tillery, met with Assistant Director Carleton Bebins, for an unannounced Case Management Incident inspection regarding an Unusual Incident that occurred on 05/06/2021. Director self-reported the incident to LPA Tillery via telephone call and via Unusual Incident Report (UIR) on 05/07/2021. LPA learned that a child was left unattended on the outdoor playground for approximately 2 to 4 minutes.


Census at time of arrival to facility was 8 children and 5 staff. During today’s inspection, LPA toured the facility and conducted staff interviews.

Prior to today’s visit, Director conducted a staff meeting to discuss the procedures on counting of children and doing a sweep of the yard before the door is shut. Another staff member was hired to assist with supervision.

Based on interviews conducted and information from the self-reported incident, it has been determined that there was a lack of supervision.

Title 22 Deficiencies have been cited on the attached LIC 809D, and an immediate civil penalty of $500 is being assessed. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files. This facility evaluation report was reviewed and discussed with the Assistant Director. A notice of site visit was issued and will remain posted for 30 days. Appeal Rights were also issued and discussed.

SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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 05/18/2021 09:02 AM - It Cannot Be Edited


Created By: Alize Tillery On 05/14/2021 at 12:01 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: FOREVER YOUNG INFANT CARE CENTER
FACILITY NUMBER: 340305706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2021
Section Cited
CCR
101229(a)(1)

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The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time.
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Director stated that she will continue to review their procedures on counting for children on a regular basis. Prior to today's visit, director conducted a meeting to review and update these procedures on 5/6/2021 and has since hired a new staff to assist with supervision.
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This requirement was not met as evidenced by: A self reported incident and interviews conducted revealed that a child was left on the outdoor playground unattended. This poses an immediate risk to the health and safety of children in care.
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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:Maria Mayorga
LICENSING EVALUATOR NAME:Alize Tillery
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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