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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483000103
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:43:44 AM

Document Has Been Signed on 10/31/2022 11:43 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: 16CENSUS: 2DATE:
10/31/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Carmen Williams - LicenseeTIME COMPLETED:
11:50 AM
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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. Effective, 10/14/22, the facility license was revoked and the revocation of the license is stayed for three years due to an incident involving a domestic abuse situation which resulted in violation of a child's personal rights on 10/12/21. LS was granted probationary license subject to the following limitations and conditions:
  • Respondent shall operate the facility in strict compliance with the regulations and statutes governing the operation of a family child care home.
  • During the period, of probation, the Department in its sole discretion may conduct an unannounced site visits for the purpose of determining whether there is full compliance with the regulations and statutes governing the operation of a family day care home.
  • Respondent shall ensure that all individuals working, residing or volunteering in the facility shall obtain criminal record clearances or exemptions prior to their initial presence in the facility and shall maintain proof of such criminal record clearances or exemptions at the facility.
  • Respondent shall maintain current personnel records of each employee at the facility and ensure that all employees have a current certificate of CPR and First Aid training and mandatory reporter training certificates on file at the facility.
  • The Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period.
  • Respondent is required to maintain an accurate, complete and current client roster which must be made available to the Department upon request.
  • Respondent shall report to the Licensing office the following: any unusual incident including, but not limited to, client death or injury which requires medical treatment, any suspected physical or psychological abuse of any clients, (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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
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: 10/31/2022
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any physical plan changes and all unexplained absences, law enforcement presence at the facility child care home, presence of A1 at the family child care home. These incidents must be reported by the next working day, and a

written report of the incident must be submitted within seven days following the occurrence of the incident.
  • For the duration of the probationary period, Respondent shall inform all current and prospective parents of children in the facility of the facility's probationary license by providing to the parents a copy of the Stipulation and Accusation. Parents shall sign an acknowledgement indicating they have received a copy of the Stipulation and Accusation. The parental acknowledgement shall be maintained in the corresponding child's file and shall be made available to the Department upon request.
  • Respondent shall maintain audible alarms that triggers an alert if anyone exits through either the front door of the home or the side door at the sunroom. The sensors of the audible alarm shall be set to be triggered at the short height of children so that children cannot slip under the sensor.
  • Respondent shall maintain the gate, external to the sunroom, with latch that can only be opened by an adult.
  • Respondent shall maintain additional gate that prevents children from eloping via sunroom side door.
  • Respondent represented to the Department that Respondent is seeking Legal Separation from A1.
  • Respondent affirms she voluntarily entered into the legal separation of her own volition and not due to pressure or suggestion by the Department.
  • Respondent agrees to exclude A1 from the facility and should Respondent permit A1 to be present at the facility, Respondent will be in violation of the Stipulation, and Department shall have the authority to rescind the probation and permanently revoke Respondent's license.
  • Should A1 come to the facility without consent of Respondent, Respondent must vall law enforcement and request law enforcement remove A1 from the premise.
  • Respondent must maintain accurate and up to date individual infant sleep plans for all infants in care. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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
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: 10/31/2022
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LPA provided a copy of and consulted on the Stipulation and Waiver; and Order with LS. During the visit, LS confirmed she did not currently have any infants enrolled into care and LPA observed two children in care with LS and one staff (S1), and there was no evidence to suggest that A1 was on the premise. LPA took a tour of the home and grounds on limits area which consisted of the Family room/one bathroom, Sunroom and backyard, and according to Department records, all adults residing and/or working at the facility obtained a criminal record clearance. Based on LPA's observations, LS was in compliance with the terms and conditions of the Stipulation and Waiver.

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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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