343624814-8-14-2024-03-CC-FSCZ-D85P27-20240814105529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624814
Report Date: 08/14/2024
Date Signed: 08/14/2024 10:55:38 AM

Document Has Been Signed on 08/14/2024 10:55 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	HENDERSON, TIA		FACILITY NUMBER:	343624814
ADMINISTRATOR/ DIRECTOR:	HENDERSON, TIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 470-1758
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	08/14/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Tia Henderson		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On Wednesday, 14 August, 2024, at approximately 9:30am, Licensing Program Analyst (LPA) Fabian Schwartz met with Licensee, Tia Henderson, for the purpose of an unannounced annual inspection. Upon arrival, LPA observed licensee supervising 6 children. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed proper ratio and capacity was being followed. Facility hours of operation are Monday through Friday 7:00am-12:00am. LPA verified that the annual fees are current. A health and safety evaluation was conducted in all areas accessible to children. Facility is a 4 bedroom, 3 bathroom two story home. Off-limit areas include: Entire Upstairs and Garage. Licensee acknowledged that children may never enter these off-limit areas. LPA observed that the facility is clean, sanitary, and in good repair. LPA observed a functioning smoke detector, carbon monoxide detector, and a full 2A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. LPA observed a poison bug killer with the stored cleaners on high shelf of pantry. During inspection, Licensee removed bug killer from facility, bringing home back into Title 22 compliance. The licensee stated there are no weapons in the home. LPA observed that there is a fenced backyard with no pool. LPA reviewed 3 children’s files which were observed to be complete. Required postings were seen outside of playroom inside facility and the children’s roster was observed. LPA observed 15-minute observation checks for napping infants. The facility has record of conducting fire drills at least every 6 months with the last fire drill being conducted on 5 Aug 24. Licensee’s CPR/First Aid card expires 12 Oct 24. Licensee’s Mandated Reporter certificate expires 10 Oct 24. Licensee understands that trainings must be completed every two years. *PAGE 1. REPORT CONTINUES ON LIC809-C..........*

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HENDERSON, TIA	FACILITY NUMBER: 343624814
	VISIT DATE: 08/14/2024

NARRATIVE

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Report Continued from LIC809.....

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

PAGE 2. REPORT CONTINUES ON LIC809-C..........

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HENDERSON, TIA	FACILITY NUMBER: 343624814
	VISIT DATE: 08/14/2024

NARRATIVE

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Report Continued from LIC809-C.....

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, 1 Type A Title 22 citation has been issued for poison not being stored behind lock and key. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. LIC9224 and Appeal Rights were provided. Licensee's signature on this report acknowledges receipt of these rights.

Exit interview conducted and report was reviewed with the licensee. During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Fabian Schwartz
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2024 10:55 AM - It Cannot Be Edited

Created By: Fabian Schwartz On 08/14/2024 at 10:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HENDERSON, TIA	FACILITY NUMBER: 343624814
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(4)

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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having a poison bug killer in an unlocked pantry which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	At time of inspection, Licensee removed poison bug killer from facility, bringing facility back into Title 22 compliance. Deficiency cleared during time of inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Amanda Blesi

LICENSING EVALUATOR NAME:

Fabian Schwartz

LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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