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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009888
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:24:34 PM

Document Has Been Signed on 05/04/2022 04:24 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: 15DATE:
05/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Kywanna ReedTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Melchisedeck Augustin and Sebastian Phouthavong conducted a Plan of Correction (POC) visit and met with Licensee, Kywanna Reed (LS). On 04/06/22, LS was cited because S1 & S2 did not have evidence of negative TB clearance, proof of immunity against the Measles, Pertussis and Influenza, as well as a current AB 1207 Mandated Reporter Training certificates. At that time, LPA, Augustin reviewed fourteen children's records which revealed C1-C14 were either missing their Immunization Record or IR were not transcribed onto the blue CDPH 286, and C3-C8, C11-C12 & C14's records did not contained signed LIC 995, and C5-C7, C11-C12 & C13's LIC 282 were either incomplete or missing, and C5-C8 & C14's LIC 700 were either incomplete or missing.

At 2:33pm, LPAs reviewed fourteen (C1-C14) children's 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. The Department is extending 04/27/22 POC due date until 05/6/22 for the purpose of LS ensuring that the children's records are complete, and a follow up inspection is warranted to review the children's records. LPAs also reviewed three staff (LS, S2 & S4) records which revealed LS did not have a current AB 1207 Mandated Reporter Training certificate, however; on 04/06/22, the facility was cited Health and Safety Code, 1596.8662(b)(1) due to S1 & S2 not having current AB 1207 Mandated Reporter Training certificates and the POC is due on 05/21/22. LS stated she would complete the online AB 1207 Mandated Reporter training module at, mandatedreporterca.com by 05/21/22.

Furthermore, during today's inspection, there were 15 children in care and facility exceeded maximum number of children for whom care may be provided at any one time, and as such, LS did not comply with California Code of Regulations, 102416.5(a).

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 following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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Document Has Been Signed on 05/04/2022 04:24 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 05/04/2022 at 03:50 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: REED, KYWANNA FCCH
FACILITY NUMBER: 483009888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
102416.5(a)

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The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by: based on LPAs' observations of 15 children in care.
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The Licensee stated she would produce a written statement which would detail how she intended to coordinate the children's schedule to ensure the capacity requirements are being met.
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This posed/poses an potential health, safety and personal risk to the children in care.
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LPA will also conduct a follow up inspection to verify and confirm the facility is complying with capacity requirements.

Email: melchisedeck.augustin@dss.ca.gov
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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