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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001308
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:58:00 PM

Document Has Been Signed on 09/17/2024 12:58 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GRAVES, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
483001308
ADMINISTRATOR/
DIRECTOR:		GRAVES, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 557-7473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 12TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
09/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria GravesTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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An unannounced annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Cindy Castro. LPA met with Maria Graves, Licensee (L1). There are currently three adults living in the home. L1 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.

During the inspection the home was toured inside and outside. The licensee (L1) was supervising three children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:30AM to 6:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the lower level of home, one bedroom, one bathroom and garage these were made inaccessible by door latch and door locking mechanism. The fireplace was screened with cardboard, licensee stated that fireplace has not been used for many years. LPA reviewed the regulation that fireplace needs to be screened to prevent access. Licensee stated that she will zip tie the screens to secure. The home was clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The wooden patio deck is used as the outdoor play area, it is fully fenced. There were no pools or other bodies of water observed in the yard. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Licensee stated that poisons are kept in the backyard shed to which children do not have access. The regulation that poisons are to be locked using a key or combination lock was reviewed. Licensee’s pediatric CPR/First Aid certification expires on 09/2026. Licensee’s mandated reporter training certification expires 06/2025. (Continue to LIC 809-C)

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRAVES, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483001308
VISIT DATE: 09/17/2024
NARRATIVE
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There is a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2-A, 10: BC. Last conducted and documented emergency/fire drill was on 09/05/2024. Licensee stated that there are no firearms or weapons in the home, none were observed during today’s visit. Three child files were reviewed. C1 and C2 records were missing Immunization Record (IR), transcribed CDPH 286, while C1-C3 records were missing LIC995A Notification of Parental Rights. Facility roster was reviewed and current.

LPA discussed 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.

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/

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, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 09/16/24.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRAVES, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483001308
VISIT DATE: 09/17/2024
NARRATIVE
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The following violations of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

An exit interview was conducted, and plans of corrections were reviewed and developed with the Licensee. Appeal Rights were provided and discussed with, Maria Graves whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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Document Has Been Signed on 09/17/2024 12:58 PM - It Cannot Be Edited


Created By: Cindy Castro On 09/17/2024 at 12:01 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRAVES, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483001308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of three children's (C1-C3) records at 11:30am which revealed that C1-C2 children's records did not contain Immunization Records and transcribed CDPH 286. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee stated she would request Immunization Records from the children's parents and submit evidence to proof to the department that C1-C2 were immunized by 10/04/24. Email: cindy.castro@dss.ca.gov & Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


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Document Has Been Signed on 09/17/2024 12:58 PM - It Cannot Be Edited


Created By: Cindy Castro On 09/17/2024 at 12:01 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRAVES, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483001308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of three children's (C1-C3) records at 11:30am which revealed all three children's records did not contain LIC995A Notification of Parental Rights. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated that she will provide all parents a copy LIC995A that acknowledges that the parent or authorized representative has received and read the LIC 995A and keep the bottom signed and dated portion as proof on file. The licensee will submit evidence to the department by 09/27/24. Email: cindy.castro@dss.ca.gov & Fax: 707-588-5099

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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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