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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500740
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:09:08 PM

Document Has Been Signed on 04/03/2024 04:09 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:CANNON, ASIAFACILITY NUMBER:
394500740
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 13CENSUS: 10DATE:
04/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Asia CannonTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 04/03/24 Licensing Program Analyst (LPA) Elvira Sierra met with licensee, Asia Cannon to deliver an amended version of a report created on 07/07/22. Present in the facility was Licensee and two assistants present caring for 10 children.

Exit interview conducted. California Code of Regulations, (Title 22, Division & Chapter number, are being cited on the attached LIC 809D.) Upon receipt of Type A citation, licensee shall post and provide copies of the LIC 809D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809D in each child's file. LPA read this report to the Licensee, Asia Cannon; She stated that she understands today’s inspection. Appeal Rights were provided, Notice of Site Visit posted and must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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 04/03/2024 04:09 PM - It Cannot Be Edited


Created By: Elvira Sierra On 04/03/2024 at 03:29 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: CANNON, ASIA
FACILITY NUMBER: 394500740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
102370(d)(1)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met
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POC; Licensee will submit proof of fingerprint clearance by the due date to the Department.
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as evidence by; LPA observed two unfingerprinted adults assisting with the children on today's inspection. This is a requirement that if not corrected poses an immediate health and safety to the children in care.
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Type A
04/04/2024
Section Cited
CCR102416.5(a)

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102416.5 Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidence by: On today's inspection LPA observed 10 children present (including 2 of Licensee's own children). This is a requirement that if not corrected poses an immediate health and safety to children in care.
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POC; Licensee stated that she will talk to parents and disenroll two of the children because her two children are off from school and present at home.
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This is a requirement that if not corrected poses an immediate risk to the health and safety to 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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
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