434411395-5-10-2024-07-CC-MKAR-D55NF8-20240510102506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411395
Report Date: 05/10/2024
Date Signed: 05/10/2024 10:25:24 AM

Document Has Been Signed on 05/10/2024 10:25 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	COVINGTON, CAMILLE		FACILITY NUMBER:	434411395
ADMINISTRATOR/ DIRECTOR:	COVINGTON, CAMILLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 733-5989
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 23	CENSUS: 3	DATE:	05/10/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:49 AM
MET WITH:	Camille Covington		TIME VISIT/ INSPECTION COMPLETED:	10:45 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 Analyst(LPA), Mandeep Kaur conducted an unannounced Annual/Random inspection. LPA met with Licensee, Camille Covington explained the reason for the inspection. Present during today's inspection were Licensee, three (3) Children , and one assistant. The hours of operation are Monday through Friday 09:00 AM to 12:30 PM. There is a board to post required postings, such as license and notification of parent's rights. LPA toured the inside and outside of the home with Licensee. Day Care Areas: Family room in back, the bathroom, and the backyard. Off Limit Areas rest of the house. Disinfectant and cleaning supplies were inaccessible to children. LPA reminded licensee that anything sharp or states to keep out of reach of children, such as blades or razors need to be inaccessible. There are age appropriate toys and equipment for children inside and outside of the home. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Licensee was reminded of fire drill to be conducted every six (6) months. Licensee stated that there are no weapons, such as firearm, stored in the home. The backyard is used for the play. Licensee stated that provides morning snacks to the children. Drinking water is available using individual water bottles. There is a kitchen at the facility for food preparation. The kitchen is equipped with refrigerators, stove, oven, microwave, dishwasher, -----------------CONTINUES ON 809 DATED 05/10/2024 PAGE 2-----------------

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COVINGTON, CAMILLE	FACILITY NUMBER: 434411395
	VISIT DATE: 05/10/2024

NARRATIVE

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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep
webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and
recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased
equipment. LPA also discussed that either licensee or an assistant needs to be present in the infant nap room during an infant is taking a nap.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

LPA reviewed two (2) children's files during today's inspection. The records reviewed include but not limited to immunization records and notification of parent's rights.

LPA reviewed 2 staff files. Statement Acknowledging Requirement to Report Child Abuse,TB Clearance and Immunizations (Measles, Pertussis, and Influenza) and required training. Based on record review, 2 out of 2 of the staff have Missing TB test and immunization records. LPA provided the Entrance checklist for Family Child Care home and discussed the immunizations and TB test requirements for the staff with Licensee. LPA reminded Licensee that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

Licensee completed the Mandated Reporter training on 09/07/2022. Licensee has a valid CPR/1st Aid, which
expires on 09/2025.

-----------------CONTINUES ON 809 DATED 05/10/2024 PAGE 3-----------------.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COVINGTON, CAMILLE	FACILITY NUMBER: 434411395
	VISIT DATE: 05/10/2024

NARRATIVE

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--------------CONTINUATION OF 809 DATED 05/10/2024 PAGE 2-------------

The adults 18 and over living in the home are Licensee and her husband. All adults have cleared criminal record and child abuse index. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or
exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00
minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, Camille Covington, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

As a result of this inspection, Type B citation was issued.

Exit interview conducted and report was reviewed with Licensee, Camille Covington. A notice of site visit has been issued and must remain posted for 30 days.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2024 10:25 AM - It Cannot Be Edited

Created By: Mandeep Kaur On 05/10/2024 at 10:08 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COVINGTON, CAMILLE	FACILITY NUMBER: 434411395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in two out of two staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	By POC, by 05/24/2024, the center will submit the proof of the Immunization records: Staff #1 and Staff #2 missing Measles and pertussis, influenza and TB test.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Belinda Devall

LICENSING EVALUATOR NAME:

Mandeep Kaur

LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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