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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009951
Report Date: 05/24/2023
Date Signed: 05/24/2023 11:18:55 AM

Document Has Been Signed on 05/24/2023 11:18 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:POWELL, DENISHIA FCCHFACILITY NUMBER:
483009951
ADMINISTRATOR:POWELL, DENISHIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 563-0903
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 4DATE:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Davion Davenport - Facility RepresentativeTIME COMPLETED:
10:15 AM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analyst (LPA), Melchisedeck Augustin conducted an unannounced Case Management visit and met with Facility Representative, Davion Davenport (A1), for the purpose of delivering several deficiencies that were observed. Upon LPA's arrival to the facility, the Licensee (LS) was not at home and LPA observed four children (C1-C4) in care with A1. Of the four children, three children were day care children and Department records revealed A1 had not obtained an approved criminal record clearance or exemption, and an immediate $500 civil penalty is being assessed because the Licensee did not ensure A1 obtain a criminal record clearance prior to residing or working in the home. It is noted that LS returned to the facility at 9:35am and the visit was resumed with LS.

Facility Representative 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.


According to A1, A1 had been working at the facility since 05/03/23 until now, and A1's job duties consisted of providing care and supervision to children in care and preparing the areas for the children's nap. A1 stated he worked more than five days at the facility, and sometimes, A1 was left alone to supervise the children. Furthermore, A1 did not furnish a current Emergency Medical Services Authorities (EMSA) approved pediatric CPR/First Aid certification, nor evidence of negative TB clearance. Prior to LPA's departure, two children were picked up from care. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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: POWELL, DENISHIA FCCH
FACILITY NUMBER: 483009951
VISIT DATE: 05/24/2023
NARRATIVE
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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(s) of California Code of Regulations, Title 22, Division 12, were cited during today's visit. Appeal Rights were provided.

LPA Melchisedeck Augustin informed licensee, Denishia Powell that this report dated 05/24/2023 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Melchisedeck Augustin informed the licensee to provide a copy of this licensing report dated 05/24/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 11:18 AM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 05/24/2023 at 09:54 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: POWELL, DENISHIA FCCH
FACILITY NUMBER: 483009951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee stated she printed the LIC 9163 and LS would ensure A1 obtain a criminal record clearance prior to working or residing in the home. The Licensee stated she intends to submit the completed LIC 9163 to the Department by 05/25/23 via email or fax.
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This requirement is not met as evidenced by: Based on LPA's observation of A1 working with four children, in addition to Department records which revealed A1 had not obtained a criminal record clearance and a $500 civil penalty was assessed. This poses an immediate health, safety and/or personal rights risk to children in care.
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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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/24/2023 11:18 AM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 05/24/2023 at 10:00 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: POWELL, DENISHIA FCCH
FACILITY NUMBER: 483009951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2023
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 was not met as evidenced by: Based on A1 being left alone with three daycare children and A1 not furnishing a
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Licensee stated she would ensure A1 complete an EMSA approved pediatric CPR/First Aid course and LS would submit A1's current certification to the Department by 06/14/23.
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current EMSA approved pediatric CPR/First Aid certification. This poss/posed 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
06/14/2023
Section Cited
CCR102369(b)(9)

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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 was not met as evidenced by: Based on A1 being left alone with three daycare children and A1 not furnishing
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Licensee stated A1 would walk in to a clinic and obtain evidence of negative TB clearance, and the Licensee intends to submit A1's evidence of negative TB clearance to the Departemtn by 06/14/23.
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evidence of negative TB clearance. This poses/posed 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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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