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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621006
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:46:27 PM

Document Has Been Signed on 03/25/2024 02:46 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STEPHENS, THEONIAFACILITY NUMBER:
343621006
ADMINISTRATOR:STEPHENS, THEONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 822-1048
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
03/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Stephens, TheoniaTIME COMPLETED:
03:00 PM
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At 1:10 p.m., Licensing Program Analyst (LPA) Pa Dao Vang met with Licensee, Theonia Stephens, for the purpose of an unannounced, required inspection. There were 6 children napping during inspection. Licensee stated that there 9 children currently enrolled. Facility hours of operation are from 7:00 a.m. - 5:00 p.m., Monday thru Friday. Off limit areas consist of: all bedrooms, the garage and the kitchen area (behind the island). Licensee understands children may never enter these off limit areas.

All individuals subject to criminal background review have obtained a criminal record clearance. 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.

A health and safety inspection was conducted in all areas accessible to children. LPA observed the required postings, a working phone, 3A-40-BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated that there are no weapons nor poisons in the home. Toxic and hazardous items were appropriately stored, inaccessible to children.

LPA reviewed staff files. Licensee's CPR/First Aid certification will expire on 10/9/2025 and Mandated Reporter Training certificate expiring 12/12/2024. LPA reviewed 6 children files with all required documents. LPA informed Licensee of location change for regional office and provided updated parents’ rights forms and postings with current address. LPA also provided a copy of the LIC9227 Individual Infant Sleep Plan to Licensee.

Continue report on LIC809-C...
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STEPHENS, THEONIA
FACILITY NUMBER: 343621006
VISIT DATE: 03/25/2024
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APPLICANT OWNS THE HOME: The licensee provided proof of control of property. Licensee understands the facility may operate with a maximum capacity of 14 children in care with an adult assistant.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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. LPA discussed about the infant sleep log required for each child under the ages of 1years old. Licensee must checking and documenting each infant sleeping every 15 minutes. LPA provided an example of the infant sleep log to Licensee.



This provider is not currently providing Incidental Medical Services IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: https://www.ada.gov/childqanda.htm.

During the exit interview, the LICENSEE Theonia Stephens, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Continue Report on LIC809-C...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STEPHENS, THEONIA
FACILITY NUMBER: 343621006
VISIT DATE: 03/25/2024
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

In the areas that were evaluated, no deficiencies were cited during inspection. A copy of this report was printed and provided to the Licensee. Exit interview was conducted and report was reviewed with Licensee Theonia Stephens. A Notice of Site Visit and appeal rights were given and must remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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