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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008718
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:03:58 PM

Document Has Been Signed on 02/22/2024 03:03 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:CLAVERIE, CLAUDIA FCCHFACILITY NUMBER:
483008718
ADMINISTRATOR:CLAVERIE, CLAUDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 704-7221
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 7DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Claudia ClaverieTIME COMPLETED:
03:15 PM
NARRATIVE
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On 02/22/24 at 9:35am upon arrival Licensing Program Analyst (LPA),Cindy Castro met with Licensee Claudia Claverie, Staff #1 (S1) and Staff#2 (S2).The purpose of this unannounced visit is to conduct a case management deficiencies. The census today is 7 children being care and supervised by licensee and two Staff.

At 9:40am while reviewing facility Guardian print out, LPA observed that S1 was not associated with facility. LPA verified S1 is background cleared and eligible. S1 has worked at prior child care facilities and S1 is currently cleared and eligible. LPA reviewed with licensee that per Title 22 Regulations, all individuals shall prior to working, residing, or volunteering in a licensed facility obtain or request a transfer of a criminal record clearance. Licensee stated that she had the transfer of background check form ready and was going to be faxing it to the department, as she might have missed this requirement when S1 returned to work for licensee. Licensee stated that S1 worked for her several years back around 2020.

During interviews corroborating statements were made by licensee that S1 has been employed by since 01/08/24. Licensee and LPA discussed a plan of correction. Licensee will submit Criminal Background Check Transfer form (LIC9182) to the Department.

As a result of today’s visit the following violations of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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Document Has Been Signed on 02/22/2024 03:03 PM - It Cannot Be Edited


Created By: Cindy Castro On 02/22/2024 at 02:24 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: CLAVERIE, CLAUDIA FCCH
FACILITY NUMBER: 483008718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
102370(d)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 102370(j)
This requirement is not met as evidenced by:
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Licensee stated she will email or fax LIC 9182 to asscociate S1, to her Guardian facilty roster as an employee and submit to the department by 02/23/24.
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Based on interview, observation and record
review, Licensee did not ensure S1 had a Criminal Record Clearance transfer before employement on 01/08/24, which poses an immediate risk to the Health, Safety and Personal rights of the children in care.
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Via email: cclrpregionalofficegeneral@dss.ca.gov
or Fax:(707)588-5099

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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: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLAVERIE, CLAUDIA FCCH
FACILITY NUMBER: 483008718
VISIT DATE: 02/22/2024
NARRATIVE
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An immediate civil penalty of $100 was assessed for S1 being in facility without transfer of Background Check today 02/22/24.

A Type A deficiency has been cited, a copy of the citation and licensing report must be posted for 30 days. The same report must be provided to Parents/Guardians and the Acknowledgment of Receipt of Licensing Reports LIC 9224 must be signed by Parents/Guardians of all enrolled children and any newly enrolled children in the next 12 months following the citation. If these requirements are not met, civil penalties per violation will be assessed.

Plan of Correction (POC) was created and licensee agreed. Appeal Rights were provided and reviewed with Licensee.

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. Exit interview conducted and report was reviewed with Claudia Claverie.

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

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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