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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624175
Report Date: 03/01/2023
Date Signed: 03/01/2023 04:12:28 PM

Document Has Been Signed on 03/01/2023 04:12 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:TATOM, TENISHAFACILITY NUMBER:
343624175
ADMINISTRATOR:TATOM, TENISHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 384-7263
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
03/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tenisha TatomTIME COMPLETED:
02:00 PM
NARRATIVE
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On March 1, 2023 at approximately 11:30AM, Licensing Program Analyst (LPA) Michelle Pascual met with Licensee, Tenisha Tatom, for an unannounced annual / one year inspection. During the inspection there was a census of six (6) children being supervised by the licensee. At the time of arrival, there were four infants with three preschoolers and no assistant present. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Garage, upstairs, dog area, shed and laundry room, Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed a fireplace/wood burning stove within the home and it is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted last year in in Jan. 2022. LPA advised Licensee to conduct an drill and update log. A T.A., was provided. Licensee's has current CPR/First aid, which expires 02/2024. Licensee’s Mandated Reporter Training expires 01/2024. Licensee understands both trainings’ must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation. (1/2)

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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 4
Document Has Been Signed on 03/01/2023 04:12 PM - It Cannot Be Edited


Created By: Michelle Pascual On 03/01/2023 at 12:38 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: TATOM, TENISHA
FACILITY NUMBER: 343624175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(2)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above with four (4 )infants out of six (6) children which poses an immediate health, safety or personal rights risk to persons in care without assistant.
POC Due Date: 03/02/2023
Plan of Correction
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Licensee will not care for more than four infants at any given time. Licensee understands that additional children must be a mix of preschoolers and school aged.
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four (4) infants out of six (6) children, without an assistant, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee will always have an assistant present when operating over a small family childcare ratio. Licensee will not operate as a large family without an assistant.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/01/2023 04:12 PM - It Cannot Be Edited


Created By: Michelle Pascual On 03/01/2023 at 12:38 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: TATOM, TENISHA
FACILITY NUMBER: 343624175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 in which a child's file did not have immunizations present. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2023
Plan of Correction
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Licensee will submit proof of immunizations for said child, directly to LPA within the 30 day time frame given.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and discussion, the licensee did not comply with the section cited above in four (4) infants out of four (4) present which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2023
Plan of Correction
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Licensee will show and provide a 15- minute log shee to LPA, on or before 4/1/2023, to serve as proof of implementation.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: TATOM, TENISHA
FACILITY NUMBER: 343624175
VISIT DATE: 03/01/2023
NARRATIVE
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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: http://www.ada.gov/childqanda.htm

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.

Licensee and LPA discussed infant sleep logs, that must be kept for all infants 2 and under.

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.

Deficiencies cited. Cont to 809 D

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days (2/2)

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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