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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622804
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:37:29 PM

Document Has Been Signed on 01/23/2025 02:37 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:STOREY, MONICAFACILITY NUMBER:
393622804
ADMINISTRATOR/
DIRECTOR:		GUARDADO, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 227-8323
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 4DATE:
01/23/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Monica StoreyTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 01/23/24, Licensing Program Analysts (LPAs) Elvira Sierra and Debbie Khashe met with licensee, Monica Storey for a Case Management inspection. During inspection visit LPAs observed an infant sleeping on her stomach on a blanket on the facility floor. LPA discussed sleeping practices and napping equipment with Licensee during today's visit.

LPA Sierra informed licensee, Monica Storey that this report dated 01/23/25 document one Type A citation. Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPAs informed the licensee to provide a copy of this licensing report dated 01/23/25 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.

Exit interview conducted and report and appeal of rights were reviewed and provided to Licensee, Monica Storey. Notice of Site Visit was posted.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 01/23/2025 02:37 PM - It Cannot Be Edited


Created By: Elvira Sierra On 01/23/2025 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: STOREY, MONICA
FACILITY NUMBER: 393622804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
102425(i)

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102425(i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible. The requirement was not met as evidence by: LPAs observed an infant sleeping on her/his stomach on the facility floor.
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POC; Licensee stated that she will ordered appropriate napping equipment for the infant in care. Deficieny will required a second inspection to verify correction.
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This is a deficiency that if not corrected poses an immediate risk to the health and safety of the 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:Bettina Engelman
LICENSING EVALUATOR NAME:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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