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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009951
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:22:47 PM

Document Has Been Signed on 08/15/2023 03:22 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: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: 10DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Denishia Powell - LicenseeTIME COMPLETED:
03:30 PM
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 Licensee, Denishia Powell (LS), for the purpose of delivering a deficiency for lack of supervision. Interviews conducted on 08/08/23 & 08/09/23 identified that LS left a minor (C4) under 14 years of age alone to supervise the daycare children. P1 reported on at least three different occasions during pickup time, P1 saw C4 left alone to supervise the children, and two witnesses (C1 & C2) described that sometimes when LS was away from the facility, another child (C4) was left alone to watch the children. California Code of Regulations (CCR) 102417(a) mandates LS to be present in the home and ensure that children in care are supervised at all times, and when circumstances require LS to be temporarily absent from the home, LS shall arrange for a substitute adult to care for and supervise the children during his/her absence.

Furthermore, C4 did not meet the age requirement to be an assistant provider, as defined in California Code of Regulations (CCR) 102352(a)(3), which indicates an Assistant Provider is a person at least 14 years of age who is primarily involved in caring for children during the hours that the home provides care. In addition, upon LPA’s arrival to the facility on 05/24/23, C4 was supervising the daycare children alone in the playroom.

Report was reviewed with LS and appeal rights were provided. A notice of site visit was given and must remain posted for 30 days along with the report and Type A citation. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The following violation of the California Code of Regulations, Title 22; Division 12; were observed. Appeal Rights were provided.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 08/15/2023 03:22 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/15/2023 at 02:44 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: POWELL, DENISHIA FCCH
FACILITY NUMBER: 483009951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
102417(a)

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The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
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Licensee stated she would produce a written statement detailing how she would ensure that an adult staff was always present during the times the Licensee was away from the facility. The Licensee intends to submit her POC to the Department by 08/16/23 via mail, email or fax.
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This requirement is not met as evidenced by: Based on three statements (P1, C1 & C2) and LPA observations which corroborated that C4 was left alone to supervise the children, and this pose/posed an immediate health, safety and/or personal rights risk to the children in care.
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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: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


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: POWELL, DENISHIA FCCH
FACILITY NUMBER: 483009951
VISIT DATE: 08/15/2023
NARRATIVE
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LPA, Melchisedeck Augustin informed licensee, Denishia Powell that this report dated 08/15/2023 document(s) one Type A citation(s) 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 08/15/2023 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: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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