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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619334
Report Date: 05/02/2022
Date Signed: 05/02/2022 03:25:34 PM

Document Has Been Signed on 05/02/2022 03:25 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:GRAVES-DIXON, RENITAFACILITY NUMBER:
343619334
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Renita Graves-DixonTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Gagandeep Singh and Erwin Tjhia met with licensee, Renita Graves-Dixon, for an unannounced annual inspection. The purpose of the inspection was explained. Licensee lives in a single story home. During the inspection, there are five day care children present with licensee. All adults living or working in the home have criminal background check on file. Licensee is operating within the capacity of this date.

LPAs inspected the day care areas with the licensee. Off limit areas: Garage. Per licensee, licensee is not using the backyard at this time. There is no pool, spa or any other body of water in the house. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Cabinets in kitchen have child protective magnetic locks installed. Knives are stored in the high cabinet in the kitchen. The house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector and working telephone available in the house. There is a variety of age appropriate toys in the house.

LPAs reviewed the facility records. LPAs observed licensee has all of the required documents posted. Licensee has record of training of preventive health and CPR card valid until March 2022. LPA remind the licensee to conduct the fire or emergency drills at least once every six months and drills must be logged. Licensee has a log in place. LPA also reviewed the present children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has record of immunization of each child in care. LPAs discussed the safe sleep regulations and provided a copy of the PIN 20-24-CCP.

See next page for continuation .............
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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: GRAVES-DIXON, RENITA
FACILITY NUMBER: 343619334
VISIT DATE: 05/02/2022
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Licensee is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed licensee has certificate on file, which was valid until March 2022.

LPA reminded the licensee that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 with copy of CA DL or CA ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

LPA encourage the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.



See next page for deficiencies cited today. The copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2022 03:25 PM - It Cannot Be Edited


Created By: Gagandeep Singh On 05/02/2022 at 02:19 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: GRAVES-DIXON, RENITA
FACILITY NUMBER: 343619334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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 as LPAs observed fire drill log indicates that the last drill was conducted in February 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee agreed to conduct and document a fire drill. LPAs reminded the licensee that the fire drill must be conducted once at least every six months.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 LPAs observed licensee's CPR training certificate expired in March 2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee agreed to obtain an EMSA approved CPR training and will maintain a valid completion certificate on file.
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:Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


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