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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500398
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:03:19 PM

Document Has Been Signed on 10/28/2022 04:03 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:GOLDEN, STEPHANIEFACILITY NUMBER:
344500398
ADMINISTRATOR:GOLDEN, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 200-7570
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
10/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Stephanie GoldenTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/28/2022, Licensing Program Analyst Katy Maestas (LPA) conducted a field visit to the Family Childcare Home (FCCH). LPA arrived at the FCCH and was met by Licensee Stephanie golden (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA toured the FCCH and observed 2 infants and 3 preschool-aged children being supervised by 2 adults. 2 school-aged children arrived later at approximately 2:30 PM. LPA observed that L1 was present in the FCCH; also present was L1's husband and child. LPA determined, through accessing Guardian, that 3 of the 4 adults were background cleared and associated to the license; however, 1 adult was not associated to the
license.
As a result, 1 deficiency was cited on a subsequent 809-D page. L1 understands that all authorized representatives of currently enrolled children, and those who enroll for up to 1 year, must sign the LIC 9224 form. An exit interview was conducted and the report was reviewed with L1. Licensee Appeal Rights were provided to L1. A Notice of Site visit was posted by LPA and must remain posted 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: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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 10/28/2022 04:03 PM - It Cannot Be Edited


Created By: Nola Maestas On 10/28/2022 at 03:29 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: GOLDEN, STEPHANIE
FACILITY NUMBER: 344500398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All
individuals subject to criminal record
review...shall prior to working...in a licensed
facility: (1) obtain a California clearance...as
required by the Department. This requirement
is not met as evidenced by:
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Licensee will provde LPA with the Drivers LIcense and LIC 9182 for the Aide. LPA will associate the Aide to the license on 10/31/22 with access to Guardian. Licensee understands that the Aide may not care for or supervise children alone until this clearance is confimed by LPA.
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Based on observation and record review, the
Licensee did not ensure that 1 Aide was associated to her license which poses
an immediate health, safety and or personal
rights risk to children in care.
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In the future, Licensee will familiarize herself with Guardian and call the Officer of the Day for verification once any individual is cleared and assocaited to her license.

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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:Nola Maestas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


LIC809 (FAS) - (06/04)
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