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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620515
Report Date: 05/13/2025
Date Signed: 05/13/2025 01:14:13 PM

Document Has Been Signed on 05/13/2025 01:14 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:LEE, CINDYFACILITY NUMBER:
393620515
ADMINISTRATOR/
DIRECTOR:		LEE, CINDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 951-8850
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
05/13/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Cindy LeeTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 05/13/25, Licensing Program Analyst (LPA) Elvira Sierra met with the Licensee, Cindy Lee for the purpose of an unannounced annual inspection. The licensee's husband was also present during the inspection. Facility hours of operation are M-F 07:00 a.m to 05:30 p.m. A review of the Facility Personnel Summary shows that all adults living and working in the home have criminal record clearances on file with Licensing Office. The licensee stated that no new residents moved into the home. Census include 6 children. Capacity specified on the license was met on today’s inspection.

A health and safety inspection was conducted in all areas accessible to children. Off limit areas are: All bedrooms, garage workshop, and detached garage. By the daycare entrance LPA observed the posting of the facility license, Emergency Disaster Plan, and Notification of Parent Rights. Home was observed clean with proper heating and ventilation. Facility maintains a working phone, 2A10BC fire extinguisher, and functioning smoke/carbon monoxide detector. Age-appropriate toys and reading material were observed. Per licensee there are no weapon in the home. Toxic and hazardous items are inaccessible to children. Fireplace in the living is barricaded with a metal gate. There is an in ground swimming pool located in the backyard. LPA inspected the swimming pool and observed that the iron fence, gate and the self closing/latching device is incompliance with Title 22 regulations.. LPA observed a rescue pole with a body hook that is not 12 feet fixed length. A life ring with exterior diameter of 20 inches with a United State Coastal Guard approval label. LPA also inspected the outdoor area. Outdoor area is fenced for supervision and was observed free of any hazards. Licensee was reminded to notify LPA of any changes on her hours of operation of changes to her off limits’ areas or vice versa.

Report continues on subsequent page 809C---

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Elvira Sierra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: LEE, CINDY
FACILITY NUMBER: 393620515
VISIT DATE: 05/13/2025
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LPA reviewed five children's files. LPA observed all required forms for the children in care are complete and maintained in the file. Current in person EMSA CPR and First Aid certification was verified and expires on 07/18/25 and AB 1207 Mandated Reporter Training was verified and expires on 2/14/27. LPA observed a current roster and fire drills are conducted at least once every six months and are properly log.

LPA verified the annual fees are current. LPA advised 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.

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.

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.

Licensee was made aware of the (LIC9227) Individual Infant Sleeping Plan, for infants under 12 months and sleep logs for all infants in care under 24 months need to be maintained in children’s files. LPA discussed and provided an example of a sleep log.

Report continues subsequent 809C...

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Elvira Sierra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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: LEE, CINDY
FACILITY NUMBER: 393620515
VISIT DATE: 05/13/2025
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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 childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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


LPA Sierra informed licensee that this report dated 05/13/25 document one number of Type A citation. Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Sierra informed the licensee to provide a copy of this licensing report dated 05/13/24 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224 ), or other written statement, must be placed in the child's file for verification.

Deficiency cited on page 809D. A notice of site visit was posted and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Cindy Lee.

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Elvira Sierra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 01:14 PM - It Cannot Be Edited


Created By: Elvira Sierra On 05/13/2025 at 12:13 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: LEE, CINDY
FACILITY NUMBER: 393620515

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above; rescue pole is not fixed leghth of 12 feet. The pool entry detection alarm that is certified ASTM Standard F2208(Standard Safety Specification for Residential Pool Alarms) must be installed and working properly, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Licensee will comply by having the requirements listed by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Elvira Sierra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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