483009411-11-29-2022-01-CC-EHTS-CLMSTH-20221129130935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009411
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:09:54 PM

Document Has Been Signed on 11/29/2022 01:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MATHEWS, SAMANTHA FCCH		FACILITY NUMBER:	483009411
ADMINISTRATOR:	MATHEWS, SAMANTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 486-6554
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	11/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Licensee Samantha Mathews		TIME COMPLETED:	01:15 PM

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	An annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. A review of staff records on 11/29/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home. During today’s inspection the home and grounds were toured. The licensee and staff were supervising nine children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 06:30AM to 06:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the three bedrooms the laundry room, and the garage. They were made inaccessible by door knob slip covers and locking mechanisms. The home was clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee was not able to produce a valid pediatric CPR and First Aid certification a deficiency was cited. Licensee nor staff were able to produce a valid AB 1207 mandated reporter training certificate an advisory note was issued. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Poisons are locked with a key or combination lock. The fireplace has been made inaccessible with Wooden cubby furniture. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The children use the back yard and front yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Five children's records were reviewed at 10:04AM; required emergency information was observed to be on file. Two children (C2, C5) were missing one or more doses of an immunization an advisory note was issued. Infants in care did not have sleep log an advisory note was issued.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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: MATHEWS, SAMANTHA FCCH	FACILITY NUMBER: 483009411
	VISIT DATE: 11/29/2022

NARRATIVE

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the 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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Samantha Mathews.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2022 01:09 PM - It Cannot Be Edited

Created By: Elpidia Hernandez Torres On 11/29/2022 at 12:29 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: MATHEWS, SAMANTHA FCCH	FACILITY NUMBER: 483009411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, licensee and staff had National CPR Foundation CPR/First Aid training certificates. National CPR Foundation is not EMSA approved. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit reciept as proof of registration to a valid EMSA Pediatric CPR/1st aid course to LPA Hernandez Torres via email, mail or fax on or before 12/13/2022. After the course is complete Licensee will email. mail or fax the training certifcate. Email: elpidia.hernandez-torres@dss.ca.gov, mail: 1450 Neotomas Ave Suite 100, Santa Rosa, CA 95405, Fax : 707-588-5099

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Leslie Lepori

LICENSING EVALUATOR NAME:

Elpidia Hernandez Torres

LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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