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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500740
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:40:47 PM

Document Has Been Signed on 10/03/2024 03:40 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/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Asia CannonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 10/03/24, Licensing Program Analyst(LPA) Elvira Sierra conducted a Case Management visit and met with Licensee, Asia Cannon. Upon arrival present in the facility were Licensee and Licensee's assistant caring for 12 children.

Licensee was made aware that she was over her ratio and that her capacity limit at any one time is 8 children. Licensee acknowledged that she was out of ratio and indicated that she is planning to apply for a increase of capacity. LPA reviewed the forms required for INCREASE OF CAPACITY with licensee and printed several forms for the licensee. Licensee stated she will mail in the increase of capacity forms and fee to the Department when she is ready. Licensee stated that two parents were late to pick up their children today and she was under the impression that facility has an hour to overlapped capacity in case a parent is late for pick up. During LPA visit 4 children were picked up.

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 reviewed this report with the Licensee, Asia Cannon; 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: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 10/03/2024 03:40 PM - It Cannot Be Edited


Created By: Elvira Sierra On 10/03/2024 at 03:05 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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
102416.5(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 12 children present with Licensee and Licensee's assistant-Facility license maximum capacity at one time is 8 children.
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POC; Licensee stated that she will make sure children schedules do not overlap to be more than 8 children at any one time. Licensee will submit a copy of the children schedules to LPA as a plan of correction.
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This is a requirement that if not corrected poses an immediate 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:Bettina Engelman
LICENSING EVALUATOR NAME:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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