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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620691
Report Date: 08/02/2023
Date Signed: 08/03/2023 11:45:05 AM

Document Has Been Signed on 08/03/2023 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARTIN, SHALESEFACILITY NUMBER:
343620691
ADMINISTRATOR:SHALESE MARTINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 416-5409
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shalese MartinTIME COMPLETED:
04:00 PM
NARRATIVE
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On 08/02/2023, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of a case management inspection. LPA arrived at the FCCH and was met by Licensee Shalese Martin (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA toured the FCCH and observed 1 infant and 3 children being supervised by L1 at nap time. Also present in the FCCH was an adult Aide and minor child. LPA determined through accessing Guardian that all required adults were background cleared and associated to the license. LPA requested and reviewed the Facility Roster.

LPA observed an infant (11 months old) in a play yard with a blanket and net over the play yard. L1 was unable to produce a Sleep Log for the specific infant that LPA observed. LPA did not observe the Infant Sleep Plan in the infant's file. LPA provided L1 with a copy of Safe Sleep Regulations and handouts.

As a result of Safe Sleep Regulations not being adhered to, 1 Type A deficiency was cited on a subsequent 809-D page. L1 understands that all parents or authorized representatives of currently enrolled children must sign the LIC 9224 form and be available to the Department for review. L1 understands that parents or authorized representatives of children enrolling for up to one year must sign the LIC 9224 form and be available to the Department for review.

An exit interview was conducted, and the report was reviewed with L1. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA 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.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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 08/03/2023 11:45 AM - It Cannot Be Edited


Created By: Katy Velazquez On 08/02/2023 at 03:06 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARTIN, SHALESE
FACILITY NUMBER: 343620691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
102425(b)3

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...(b)cribs or play yards shall be free from all loose articles and objects......
3 There shall be no objects hanging above or attached to the ...crib.
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L1 and Aide Martin will read the packet on Safe Sleep Regulations that LPA provided. L1 and Aide will email LPA a signed statement by closing on 08/03/2023. The statement will include that both L1 and Aide read the packet and will abide by all Safe Sleep Regulations.

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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:Jeanne Smith
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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