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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009971
Report Date: 09/21/2022
Date Signed: 09/21/2022 01:11:44 PM

Document Has Been Signed on 09/21/2022 01:11 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:CASTON, MAXINE FCCHFACILITY NUMBER:
483009971
ADMINISTRATOR:CASTON, MAXINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 557-4375
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Maxine Caston - LicenseeTIME COMPLETED:
01:30 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 09/21/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home. Licensee 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.

During today’s inspection the home and grounds were toured. The Licensee (LS) and one staff (S1) were supervising three children, and the facility was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 5:00am - 11:45pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the main bedroom, living room, family room, dining room, kitchen, and dog room, and were made inaccessible by means of a child safety gate.

There is a working telephone in the home. There is a functional smoke detector and carbon monoxide detector; and a fully charged fire extinguisher rated at least 2A10BC. The top of the staircase in the backyard was barricaded with a child safety gate. The wood burning fireplace was screened with large potted plants. LPA did not observe any poison(s). There were no firearm(s) or other dangerous weapons stored on the premise. Two staff (S1 & LS) records were at 10:02am which contained current AB 1207 Mandated Reporter Training certificates, required Immunization Records, and Criminal Record Statement (LIC 508). (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 01:11 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/21/2022 at 11:15 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: CASTON, MAXINE FCCH
FACILITY NUMBER: 483009971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnish evidence to prove she conducted 15 minute checks while C1 napped. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee stated she would initiate and document 15 minute checks for C1 on the infant sleep log and Licensee would submit evidence to the Department to prove that 15 minute checks were initiated. Licensee stated she would produce and submit a written plan to show how she intends to comply with the regulation.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing records for C1 & C2 which revealed C1 & C2 were missing LIC 700 & LIC 627. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee stated she would provide licensing forms 627 & 700 to the parents of C1 & C2 to complete and the Licensee would submit the completed forms to the Department by 10/05/22 via mail, email, or fax. 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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/21/2022 01:11 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/21/2022 at 11:15 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: CASTON, MAXINE FCCH
FACILITY NUMBER: 483009971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing two of three children's (C1-C3) records at 10:40am which revealed C1 & C2 were missing LIC 995. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee stated she would provide LIC 995 to the parents of C1 & C2's and obtain parents signatues, and Licensee would submit the completed forms to the Department by 10/05/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of the facility roster of the children currently in care which revealed the roster was incomplete. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee state she would complete the facility roster of the children currently in care and the Licensee would submit the completed roster to the Department by 10/05/22 via mail, email or fax. 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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2022 01:11 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/21/2022 at 11:15 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: CASTON, MAXINE FCCH
FACILITY NUMBER: 483009971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing two out of three children's (C1-C3) at 10:40 which revealed C1 & C2 were missing LIC 282. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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The Licensee stated she would provide LIC 282 to the parents of C1 & C2, obtain signatures of the parents on the forms, and Licensee woud submit evidence of the completed forms to the Department by 10/05/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102418(a)
a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing evidence to prove that C1 & C3 were immunized. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee stated she would request Immunization records from C1 & C3's parents and Licensee would submit evidence of the children's immunization to the Department by 10/05/22 via mail, email or fax. 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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


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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: CASTON, MAXINE FCCH
FACILITY NUMBER: 483009971
VISIT DATE: 09/21/2022
NARRATIVE
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At 10:40am, LPA requested three children’s records (C1-C3), however; the Licensee did not furnish record for two out of three children (C1 & C2). C1 & C3 were missing Immunization Records, and C1 & C2 were missing LIC 627, LIC 700, 995, 282, 9150.

During today’s inspection, LPA observed one child (C1) under 24 months old enrolled in care and there was a total of two play yards available. The Licensee did not furnish evidence to prove she was conducting 15-minute checks while C1 napped. The facility conducted an emergency disaster drill within the past six months and the last drill was documented on 09/21/22. The facility roster of the children in care was reviewed and appeared to be incomplete. The Licensee's EMSA approved pediatric CPR/First Aid certification expire on 11/2022. The backyard was fully fenced and there were no pools or other bodies of water observed in the yard.

The facility is not providing Incidental Medical Services (IMS) to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm. 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.

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 the California Code of Regulations, Title 22; Division 12 were cited during today’s visit. Appeal Rights were provided. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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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: CASTON, MAXINE FCCH
FACILITY NUMBER: 483009971
VISIT DATE: 09/21/2022
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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