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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620691
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:29:57 PM

Document Has Been Signed on 10/27/2022 01:29 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:MARTIN, SHALESEFACILITY NUMBER:
343620691
ADMINISTRATOR:MARTIN, SHALESEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 416-5409
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
10/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Shalese Martin TIME COMPLETED:
01:45 PM
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On October 27, 2022, Licensing Program Analyst (LPA) Stacey Williams and Licensing Program Manager (LPM) Jeanne Smith met with Licensee,Shalese Martin to conduct a case management visit regarding an incident that occurred on 1/31/2022. It was revealed through interviews that Child 1 (C1) was crying during nap time on 1/31/2022 and climbed out of their play pen several times and once climbed into another child’s play pen. The Licensee was not home during nap time and left her two Assistants to supervise the children on 1/31/2022. Assistant 1 (A1) stated they put C1 back into C1’s play pen each time C1 climbed out until C1 finally fell asleep in play pen. It is a violation of children’s personal rights to try and restrain a child in any way against their will as C1 demonstrated when climbing out of C1’s play pen after being put back several times by A1. Based on the incident described above a Type A Deficiency is being cited today on page two of this report.

An exit Interview was conducted with Licensee. Appeal Rights were provided, and LPA posted a Notice of Site Visit which must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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Document Has Been Signed on 10/27/2022 01:29 PM - It Cannot Be Edited


Created By: Stacey Williams On 10/27/2022 at 10:18 AM
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: MARTIN, SHALESE
FACILITY NUMBER: 343620691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
102423(4)

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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting: or withholding shelter, clothing, medication, or aids to physical functioning.
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Licensee will review with her Assistants Title 22 Regulations for Family Child Care Homes, section 102423 Personal Rights and ensure her Assistants understand the importance of not violating children’s personal rights.
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This requirement was not met as evidenced by: On 1/31/2022 Assistant 1 made Child 1 stay in their play pen during nap time even though Child 1 demonstrated they did not want to be in the play pen by repeatedly climbing out.This poses an immediate risk to the health and safety of children in care.
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 In addition, the Licensee and her Assistants will view the video on children’s personal rights on the childcare licensing website by 10/31/22. Licensee will submit a statement indicating the video has been viewed by herself. Video link: https://ccld.childcarevideos.org/parents-and-families/childrens-personal-rights-in-child-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:Bettina Engelman
LICENSING EVALUATOR NAME:Stacey Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
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