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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009888
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:44:08 PM

Document Has Been Signed on 06/06/2022 02:44 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:REED, KYWANNA FCCHFACILITY NUMBER:
483009888
ADMINISTRATOR:REED, KYWANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 654-8563
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 13DATE:
06/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Kywanna Reed - LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit and met with Licensee, Kywanna Reed (LS). LPA conducted a prior visit on 05/04/2022 to review children (C1-C14) and staff (LS, S1-S2) records which revealed C1, C3-C4 were missing LIC 700, C8 was missing LIC 627 and LIC 995, as well as C14 was missing LIC 995 and LIC 9150. Furthermore, on 05/04/22, the facility was cited for operating over capacity because the facility had 15 children in care and facility exceeded maximum number of children for whom care may be provided at any one time.

During today's inspection, the Licensee (LS) and one staff (S1) were supervising thirteen children and operating within the licensed capacity and ratio requirements. Licensee submitted a copy of her current AB 1207 Mandated Reporter Training certificate, as well as LPA reviewed five children's (C1-C3, C8 & C14) records at 1:32pm which revealed the children's records were complete. LPA cleared CCR 102416.5(a), 102417(g)(7), 102418(a), 102419(d), 102417(m)(3) and Health and Safety Code 1597.622(a)(1) deficiencies that were cited on 04/06/2022 and 05/04/2022, and LPA provided Letter of Deficiencies Citations Cleared to the Licensee.

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 inspection.

LPA Augustin provided Licensee, Kywanna Reed with Letter of Deficiency Citation Clearance pertaining to CCR 102416.5(a) and the Licensee understood the requirement to post the letter for 30 consecutive days, and in accordance with Health and Safety 1596.8595(b)(1).
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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