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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009888
Report Date: 06/21/2023
Date Signed: 06/21/2023 11:47:50 AM

Document Has Been Signed on 06/21/2023 11:47 AM - 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:
06/21/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kywanna Reed - LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin conducted a Case Management - Legal/Non-Compliance visit to the facility and met with Licensee, Kywanna Reed (LS). On 03/20/23, the facility attended a Non-Compliance Conference (NCC) with the Department to discuss multiple citations which were issued. On 02/15/23, the facility was cited a type A citation as a result of a substantiated complaint alleging a lack of supervision resulting in severe injuries to an infant under 12 months old. In addition, the facility was cited for operating out of ratio when it had only one staff to supervise nine children and for not complying with infant safe sleep requirements when LS could not provide evidence documenting that 15-minute check(s) were being conducted for napping infant(s) under 24 months old. Furthermore, LS was cited a type A deficiency for operating over the licensed capacity of 15 children in care, as well as seven type B deficiencies for not complying with requirements related to children's records, personnel required immunization, and lack of evidence of negative TB clearance; and not furnishing current AB 1207 Mandated Mandated Reporter Training certificates for two staff.

During today's visit, LPA observed 13 children in care with LS and one staff (S1), and the facility was operating within the licensed capacity and ratio requirements. The serving hatch or opening in the wall between the kitchen & family room was free from obstruction, allowing for visibility into the family room. The large window with blind shades installed that is in the family room had the shades rolled all the way up to allow for visibility into the backyard. According to LS, she kept the serving hatch free and cleared of obstruction(s), there was always two or more staff present to supervise the children, and LS had a diagram/handout of the ratio requirements posted near the front entrance for staff to reference. Furthermore, LS stated she never accepted or had more children than what the license allowed for. LPA reviewed two staff (LS & S1) records at 9:26am which revealed LS and S1 did not have a current EMSA approved pediatric CPR/First Aid certification. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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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: REED, KYWANNA FCCH
FACILITY NUMBER: 483009888
VISIT DATE: 06/21/2023
NARRATIVE
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Eight children's (C1-C8) records were reviewed at 9:49am which revealed several children's records were either missing or did not contain parents' signature on various licensing forms which includes Affidavit Regarding Liability Insurance for Family Child (LIC 282), Consent for Emergency Medical Treatment (LIC 627), Notification of Parents Rights (LIC 995A), Parent Notification of Additional Children (LIC 9150), and immunization records (IR) were recorded on incorrect CDPH 286.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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 PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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: REED, KYWANNA FCCH
FACILITY NUMBER: 483009888
VISIT DATE: 06/21/2023
NARRATIVE
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During the exit interview, the Licensee, Kywanna Reed, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. 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. The following violation of Title 22, Division 12; were cited during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2023 11:47 AM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/21/2023 at 11:17 AM
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: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2023
Section Cited
CCR
102416(c)

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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: Based on staff (LS & S1) records reviewed at 9:26am which revealed staff did not have a
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Licensee stated she registered for an EMSA approved pediatric CPR/First Aid course and Licensee intends to complete the course and submit her current certification to the Department by 07/01/23 via mail, email or fax.
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current EMSA approved pediatric CPR/First Aid certification. 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
Type B
07/01/2023
Section Cited
CCR102421(a)

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The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by: Based on LPA's review of eight children's (C1-C8) records at 9:49am which revealed multiple children either were missing or did not have various licensing form(s) signed. This
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Licensee stated she would review all children's records and ensure that all required licensing forms were signed and maintained. Licensee shall submit evidence of the children's completed records to the Department by 07/01/23 via mail, email or fax.
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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: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
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