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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009535
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:00:17 PM

Document Has Been Signed on 12/07/2021 02:00 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SCOTT, DEBRON FCCHFACILITY NUMBER:
483009535
ADMINISTRATOR:SCOTT, DEBRONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 492-7705
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Scott Debron - LicenseeTIME COMPLETED:
02:10 PM
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 12/07/2021 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 is currently one adult living in the home. The facility is partnered with Child Start Inc and Solano Quality Counts.

During today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising six 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 7:00AM to 5:00PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire upper level and were made inaccessible by door locking mechanism and children's safety gates. The children utilized the converted garage for additional play space. The home was clean and orderly and was at a comfortable indoor temperature. The fireplace on the second floor was made inaccessible by a physical door barrier. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s pediatric CPR certificate expire on 05/16//22 and First Aid expire on 06/07/22. LS furnished her AB 1207 Mandated Reporter Training certificate which expire on 05/26/22. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The staircase that leads to the backyard was barricaded with a wrought iron gate. The stairways in the backyard balcony were barricaded with wrought iron fencing. There is a functional smoke and carbon monoxide detectors; and a fully charged 2A10BC fire extinguisher at the facility. The Licensee stated that poisons were not stored on site and LPA did not observe any poison during the inspection. Staff (LS, S1 & S2) records were reviewed at 10:30am and records reviewed revealed that S1 & S2’s records did not contain evidence of negative TB clearance, as well as S2 was missing proof of immunity against Measles, Pertussis and Influenza. During today’s inspection, there was one infant in care and Licensee furnished evidence that 15 minutes checks had been conducted for the napping infant. The facility conducted an emergency drill on 11/15/21. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SCOTT, DEBRON FCCH
FACILITY NUMBER: 483009535
VISIT DATE: 12/07/2021
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LPA reviewed six children’s (C1-C6) records at 11:05am, and emergency and identification forms were on file, however; C3’s record was missing immunization record (IR) and the IR was not fully transcribed onto the CDPH 286. The Licensee stated there were no firearms and/or other dangerous weapons in the home. The backyard appeared to be free of hazards and was fully fenced. There were no pools or other bodies of water observed in the yard. The facility is not providing Incidental Medical Services (IMS) to children in care.

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

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.

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

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.



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: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2021 02:00 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 12/07/2021 at 01:09 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SCOTT, DEBRON FCCH
FACILITY NUMBER: 483009535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed at 10:30am, the licensee did not comply with the section cited above. Staff records reviewed revealed that S2's record was missing proof of immunity against the Mealses, Pertussis and Influenza, in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2021
Plan of Correction
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The Licensee stated she would submit proof of immunity against the Measles, Pertussis and Influenza for S2. The Licensee stated she would submit staff required immunization to the Department by 12/14/21 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
Section Cited
CCR
102369(b)(9)
Application for Initial License. Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed at 10:30am, the licensee did not comply with the section cited above. Staff records reviewed revealed that S1 & S2's were missing evidence of negative TB clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2021
Plan of Correction
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The Licensee stated she would obtain evidence of negative TB clearance from S1 and S2 and she would submit evidence of TB clearance for S1 and S2 to the Department by 12/14/21 via mail, email or fax.

Email: melchisedeck.augustin@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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021


LIC809 (FAS) - (06/04)
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