393602276-4-4-2024-53-CC-ESIA-D3ZT84-20240404142943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393602276
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:29:49 PM

Document Has Been Signed on 04/04/2024 02:29 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	CARLSON, SARAH		FACILITY NUMBER:	393602276
ADMINISTRATOR/ DIRECTOR:	CARLSON, SARAH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 298-9554
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	04/04/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Sarah Carlson		TIME VISIT/ INSPECTION COMPLETED:	02:40 PM

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 04/04/24, Licensing Program Analyst (LPA) Elvira Sierra conducted an unannounced annual inspection and met with Licensee, Sarah Carlson. Facility hours of operation are M-F from 05:30 am to 08:30am and then 11:30am to 05:30pm. Licensee stated there are no new residents living in the home since licensure. Form (LIC 126), Entrance Checklist for Family Child Care Homes, was provided to Licensee. Upon arrival LPA observed four children being supervised by Provider's Assistant. Licensee arrived later during the inspection. A health and safety inspection of all areas accessible to children was conducted and the following was observed. Home appears orderly and suitable for children. Off limit areas are: All bedrooms, Kitchen, and Living room area will be only used as a transition to the children's bathroom, and backyard. The licensee acknowledged that children may never enter these off-limit areas. Hazardous items were stored inaccessible to children in care. Napping equipment and age-appropriate toys/play equipment were observed. There is a weapon in the home that was observed to be stored according to regulations. LPA also observed the iron fenced surrounding the swimming pool is in good repair and meet Title 22 regulations. A working telephone, 2A10BC fire extinguisher and functioning smoke and carbon monoxide detectors were observed at the home. The licensee was advised that prior to making alterations or additions to the home or grounds, the licensee should notify the Department of the proposed changes. Facility provides meals for clients. Last fire drills is properly documented and conducted at least once every six months. Licensee transport clients. Four children’s files were reviewed and are completed. Preventative health and current pediatric CPR and first aid was verified for Licensee. CPR expires on 02/25. LPA explained to Licensee that absences shall not exceed 20 percent of the hours that the facility is providing care per day. Licensee must notify the department anytime facility is closing for vacation or any other leave that requires to be absence more than 20 percent per day. Report continues on subsequent page 809C---

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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

FACILITY NAME: CARLSON, SARAH	FACILITY NUMBER: 393602276
	VISIT DATE: 04/04/2024

NARRATIVE

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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.

Licenses acknowledge that a Plan for Providing IMS must be submitted to the Department if provided. 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 does not care for infants. 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/process.

The 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.

During the exit interview, the LICENSEE, Sarah Carlson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Sarah Carlson.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2024 02:29 PM - It Cannot Be Edited

Created By: Elvira Sierra On 04/04/2024 at 02:24 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: CARLSON, SARAH	FACILITY NUMBER: 393602276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

102416 Personnel Requirements (c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having an assistant alone caring for the children with no CPR certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	POC; Licensee will submit proof of CPR certification for provider's assistant by the due date.

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:

Bettina Engelman

LICENSING EVALUATOR NAME:

Elvira Sierra

LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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