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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621390
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:28:17 PM

Document Has Been Signed on 10/16/2024 12:28 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STEPHEN, DAISYFACILITY NUMBER:
393621390
ADMINISTRATOR/
DIRECTOR:		STEPHEN, DAISYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 802-7171
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
10/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Daisy StephenTIME VISIT/
INSPECTION COMPLETED:
11:37 AM
NARRATIVE
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On October 16, 2024, Licensing Program Analyst (LPA) Stacey Williams met with Licensee, Daisy Stephen to gain signature for a report generated from an inspection conducted on October 10, 2024. The report on October 10, 2024 read as follows:

On October 10, 2024, Licensing Program Analyst (LPA) Stacey Williams met with Facility Representative, Talya Siv for the purpose conducting a case management inspection. Present in the facility were the Licensee's two Assistants and daughter. Facility Representative informed LPA that Licensee was out of town due to a medical concern. Facility Representative and Licensee's Assistants were observed supervising seven preschool age children.

LPA inspected the facility and observed the care and supervision of the children. LPA also discussed with the Licensee via telephone requirements of being present in the home per regulation, 102417(a) and when circumstances require the licensee to be temporarily absent, absences shall not exceed 20 percent of the hours that the facility is providing are per day. During today's inspection, Facility Representative and Licensee's Assistant informed LPS that the Licensee is out of town and the childcare will be closed on 10/11/24 and 10/14/24.



An exit interview was conducted and appeal rights were discussed with Facility Representative, Talya Siv and a Notice of Site Visit posted.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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Document Has Been Signed on 10/16/2024 12:28 PM - It Cannot Be Edited


Created By: Stacey Williams On 10/16/2024 at 11:37 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: STEPHEN, DAISY
FACILITY NUMBER: 393621390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
102417(a)

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The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
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Licensee will review regulations pertaining to operation of a family childcare home (102417).Facility Representative was provided a copy of the regulations during today's inspection.
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This requirement was not met as evidenced by: Licensee was not present in the home upon arrival or during the inspection. Licensee's daughter and Assistant stted that the Licensee was out of town due to a medical concern and the childcare will be closed on 10/11/24 and 10/14/24.
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Licensee will write a statement of understanding that the regulation has been reviewed and compliance will be met regarding Licensee's requirement of being present in the facility 80% of the operation hours. Plan of correction date is 11/8/24.

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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:Bettina Engelman
LICENSING EVALUATOR NAME:Stacey Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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