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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009888
Report Date: 02/15/2023
Date Signed: 02/15/2023 05:15:08 PM

Document Has Been Signed on 02/15/2023 05:15 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: 18CENSUS: 10DATE:
02/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Darion Winston & Kywanna Reed TIME COMPLETED:
04:30 PM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analyst (LPA), Melchisedeck Augustin conducted a Case Management visit to deliver several deficiencies. Upon LPA's arrival, LPA observed only one staff (S1) providing care and supervision for a total of nine children, of which, eight children including one child (C1) that was over 12 months old were either napping on a cot or a play yard in the family room, and another child was sitting in a low to the ground chair watching Television in the living room. Furthermore, LPA requested evidence to prove that 15-minute checks had/was being conducted for C1, however; S1 did not furnish evidence to prove 15-minute checks had been conducted. The facility did not comply with California Code of Regulations (CCR) 102416.5(e) and 102425(j)(2)(D)(c) which respectively indicates if no assistant provider is present at a Large Family Child Care Home, then the LS shall comply with the capacity requirements for a Small Family Child Care Home, and the provider shall check and document the time of each 15-minute check.

Shortly after, the Licensee (LS) arrived at the facility and at which time, LS stated she did not have evidence to show that 15 minute check(s) had been conducted for C1. LPA discussed the ratio and infant safe sleep requirements, as well as LPA provided full physical copies of CCR 102352, 102416.5 & 102425 to LS. LS stated she understood and appeared to have acknowledged the CCR. 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. Exit interview conducted and report was reviewed with the licensee, Kywanna Reed.

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: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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 02/15/2023 05:15 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/15/2023 at 03:52 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: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
102416.5(e)

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If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by: Based on LPA's observations of 9 children in
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Licensee stated she would ensure that another staff be present whenever she left or if she had more than 8 children in care. The Licensee stated she would produce a written plan to demonstrate how she intended to comply with CCR 102416.5(e).
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care with S1 upon LPA's arrival to the facility. This poses/posed a potential health, safety and/or personal rights risk to the children in care.
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The Licensee intends to submit her POC to the Department by 02/22/23 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
02/22/2023
Section Cited
CCR102425(j)(2)(D)(c)

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Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check.

This requirement is not met as evidenced by: Based on S1 and LS not furnishing evidence to
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LS stated she would initiate 15 minute checks for C1 and LS would document four days of 15 minute checks while C1 napped, and LS would submit evidence to show the initiation of 15 minute checks for C1 by 02/22/23.
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prove that 15 minute checks had/was being conducted while C1 napped. This poses a potential health, safety and/or personal rights risk to the children in care.
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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: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
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