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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483000103
Report Date: 06/24/2022
Date Signed: 06/24/2022 11:42:38 AM

Document Has Been Signed on 06/24/2022 11:42 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:WILLIAMS, CARMEN FAMILY CHILD CARE HOMEFACILITY NUMBER:
483000103
ADMINISTRATOR:WILLIAMS, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 642-0912
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 23CENSUS: 4DATE:
06/24/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carmen WilliamsTIME COMPLETED:
11:45 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), Melchisedeck Augustin made an unannounced Case Management – Legal/Non-Compliance visit to the facility and met with Licensee, Carmen Williams (LS) for the purpose of ensuring compliance with the terms of the Stipulation or Decision and Order. The facility license is currently on probation due to an incident involving the elopement of two children which resulted in absence of supervision on 02/08/19. A review of staff records on 06/24/22 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA took a tour of the home and grounds on limits areas which consist of the Family room/one bathroom, Sunroom and backyard. LS and one staff (S1) were supervising four children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The home was observed to be clean and orderly. LS installed several devices to prevent any further incident(s) of child elopement which includes installation of either wrought iron or wooden safety gates at the facility entrance(s)/Exits, locking mechanisms and latches installed on entrances/exits doors, video cameras in interior sunroom and exterior perimeter backyard, functional audible alarm devices installed in the wooden gates in the backyard, as well as video camera which monitors each entrances/exits. The cameras are equipped with audio capabilities and motion detection that is linked to and sends images, video clips and multi alerts/signals to two different panels screens, as well as alerts are sent to the LS' mobile, facility's main phone and staff phones.

LPA discussed LS’s responsibility to provide and comply with supervision requirement(s) and LS stated she acknowledged and understood the requirements of providing supervision. Additionally, LPA consulted on an Exclusion Order of an adult (A1) at the facility which became effective, 05/23/22. LPA verified that A1 was not present or residing at the facility and LS stated A1 did not reside in or worked at the facility. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WILLIAMS, CARMEN FAMILY CHILD CARE HOME
FACILITY NUMBER: 483000103
VISIT DATE: 06/24/2022
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
26
27
28
29
30
31
32
LPA provided LS with the Family Child Care Home Addendum to Notification of Parents’ Rights, regarding Removal/Exclusion (LIC 995) to notify parents and/or authorized representatives of A1’s exclusion as required by California State law, as well as LPA reminded LS that A1 cannot be present whenever day care children are present and during the facility's operating hours. The Licensee understands and is aware that A1 cannot be present at the facility when day care children are in care, and violation of the order may result in an assessment of an Immediate Civil Penalty of $500.

Exit interview conducted and report was reviewed with the licensee, Carmen Williams. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The were no violation(s) of the California Code of Regulations, Title 22; Division 12 cited during today’s visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2