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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483000103
Report Date: 06/04/2025
Date Signed: 06/04/2025 10:44:43 AM

Document Has Been Signed on 06/04/2025 10:44 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/
DIRECTOR:		WILLIAMS, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 642-0912
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
06/04/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Carmen WilliamsTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Glenn Ouye made an unannounced Case Management – Legal/Non-Compliance visit to the facility and met with Licensee, Carmen Williams 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 Effective, 10/14/22, the facility license was revoked and the revocation of the license is stayed for three years due to an incident involving a domestic abuse situation which resulted in violation of a child's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. The licensee 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)
NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Glenn Ouye
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/04/2025
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any physical plan changes and all unexplained absences, law enforcement presence at the facility 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 sun room. 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 sun room, with latch that can only be opened by an adult.
  • Respondent shall maintain additional gate that prevents children from eloping via sun room side door.
  • Respondent must maintain accurate and up to date individual infant sleep plans for all infants in care.

LPA verified a copy of the Stipulation and Waiver; and Order which is posted just inside the main day care entrance, the licensee posted each page of the Stipulation and Waiver; and Order for parent's viewing. During the visit LPA Ouye verified that two children over two years old and four infants were present and being supervised by the licensee and her assistant. LPA took a tour of the home and grounds on limits area which consisted of the living room, family room, one bathroom, Sun room and backyard. All adults residing and/or working at the facility obtained a criminal record clearance. Based on LPA's observations and record review, the licensee was in compliance with all of the terms and conditions of the Stipulation and Waiver; and Order.

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.
NAME OF LICENSING PROGRAM MANAGER: Leslie Lepori
NAME OF LICENSING PROGRAM ANALYST: Glenn Ouye
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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