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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621390
Report Date: 09/30/2021
Date Signed: 09/30/2021 12:43:06 PM

Document Has Been Signed on 09/30/2021 12:43 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:STEPHEN, DAISYFACILITY NUMBER:
393621390
ADMINISTRATOR:STEPHEN, DAISYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 802-7171
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Daisy StephenTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Manger (LPM) Bettina Engelman and Licensing Program Analyst (LPA) Christopher Jackson met with licensee Daisy Stephen regrading an incident that occurred but was not reported to the Department.

Reporting Requirements, Section 102416.2 were discussed and provided to the licensee during today's visit.

An exit interview was conducted. A notice of site visit was provided and should remain posted for a period of 30 days for parental review. Licensee was encouraged to the visit the departments website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of this form.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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 09/30/2021 12:43 PM - It Cannot Be Edited


Created By: Christopher Jackson On 09/30/2021 at 11:46 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: STEPHEN, DAISY
FACILITY NUMBER: 393621390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
102416.2(b)

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The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. This requirement was not met as evidenced by,
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Licensee will provided a written Unusual Incident form LIC 624B to the department by 10/08/21. Licensee acknowledged during today's inspection she understands reporting requirements and will abide with regulations and will report all incidents.
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licensees did not report an unusual incident that took place at the home. This poses a potential health and safety risk to children in care.
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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:Justin L Denton
LICENSING EVALUATOR NAME:Christopher Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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