<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622066
Report Date: 12/06/2023
Date Signed: 12/06/2023 11:20:54 AM

Document Has Been Signed on 12/06/2023 11:20 AM - 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:HILL, SUSANFACILITY NUMBER:
393622066
ADMINISTRATOR:SUSAN HILLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 967-8394
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Susan HillTIME COMPLETED:
11:30 AM
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
Licensing Program Analysts (LPAs) Elizabeth Santiago and (LPM) Chayntel Hunter met with Licensee, Susan Hill to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/29/2023. During today's visit the facility was toured. No children were present in care, at time of inspection.

On 11/29/2023 the department received a UIR stated that child (C1) was dropped off at the wrong school. LPAs interviewed the Licensee and other witnesses who were present during the incident. LPAs also obtained police report from Stockton Police Department (PD). An interview with the Licensee revealed that Licensee was instructed to drop C1 off at gate B “at the school down the street by the church,” which the Licensee believed she did. Interviews revealed that the Licensee did not clarify the name of the school with the parent nor was there documentation to show that the Licensee was given the exact name and address of the school. Interviews conducted revealed that the Licensee dropped off C1 to gate b and W2 took the child to see if C1 was enrolled in the school. Upon realizing C1 was not enrolled at Astronaut JMH Licensee had already left so W1 and W2 contacted Stockton PD. Licensee was advised to update transportation waiver to include the name of the school as well as drop off procedures.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

Facility evaluation report was reviewed and discussed with the Licensee. Exit interview was conducted. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.

The following Title 22 Deficiency is being cited on the subsequent 809-D page.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 2
Document Has Been Signed on 12/06/2023 11:20 AM - It Cannot Be Edited


Created By: Elizabeth Santiago On 12/06/2023 at 10:05 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: HILL, SUSAN
FACILITY NUMBER: 393622066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
102421(b)

1
2
3
4
5
6
7
102421 Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required…
This requirement was not met by :
1
2
3
4
5
6
7
C1 is no longer in care. No file will be obtained. Licensee will ensure that children's files are maintained prior to future enrollments.
8
9
10
11
12
13
14
 Based on observations and interviews conducted, Licensee stated they did not have C1’s file upon enrollment which poses a potential health, safety, or personal rights risk to children in care.
8
9
10
11
12
13
14
Type B
01/08/2024
Section Cited
CCR101223(a)(2)

1
2
3
4
5
6
7
101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations,.. To meet their needs. This requirement was not met by :
1
2
3
4
5
6
7
Licensee will ensure that all documentation's are completed for all children and will ensure that transportation agreement is in children's packet to include specific drop off procedures with name of school and address.
8
9
10
11
12
13
14
due to lack of communication C1 was dropped off at the wrong school and then taken to unfamiliar places by law enforcement.
8
9
10
11
12
13
14
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:Chayntel Hunter
LICENSING EVALUATOR NAME:Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2