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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483010050
Report Date: 08/25/2022
Date Signed: 08/29/2022 03:39:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/10/2022 and conducted by Evaluator Elpidia Hernandez Torres
COMPLAINT CONTROL NUMBER: 01-CC-20220810153057
FACILITY NAME:PAYNE, JESSICA FCCHFACILITY NUMBER:
483010050
ADMINISTRATOR:PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:14CENSUS: 8DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Licensee Jesscia Payne TIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Day care is not kept clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elpidia Hernandez Torres, met with Licensee, Jessica Payne to conduct a subsequent complaint investigation inspection on 08/25/2022 at 04:00PM for the purpose of delivering the findings regarding the above allegation. LPA previously met with Licensee on 08/16/2022 to discuss the purpose of the visit. It was alleged that the day care is dirty and there is trash all on the side of the house.

During the course of the investigation, interviews were conducted with Licensee and two adults between 08/16/2022 and 08/17/2022 and observations made. During a tour of the home, LPA observed that the inside of refrigerator was unclean specifically the bottom two drawers had an unidentified liquid spilled, and the kitchen countertop had a dirty blender and other litter items. The outside side yard had debris piled up and the fence was not sturdy with a missing panel. Licensee stated back yard and side yards are off limits, however the side yard and back yard was not made inaccessible to all children in care as the locking mechanism on the sliding glass door did not fully secure and prevent access to the outdoor area. According to interviews, the side yard and the back yard have been used by both daycare children and Licensee’s own children during daycare hours.
Continued- on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 01-CC-20220810153057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050
VISIT DATE: 08/25/2022
NARRATIVE
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Based on interviews, observations, and evidence received, the preponderance of evidence standard has been met and the above allegation is found to be substantiated. The California Code of Regulations, Title 22, Division 12 & Chapter 1, section is being cited on attached LIC 9099D . This report was reviewed with the Licensee and an exit interview was conducted. Licensee’s signature was recorded on this Complaint Investigation Report (CIR), a copy was provided and Licensee’s confirmation of read receipt is on file. Notice of Site Visit shall be posted for 30 days. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20220810153057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited
CCR
102417(b)
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(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.
This requirement was not met as evidence by. . .
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Licensee has a set date to haul away debris, and has cleaned the kitchen counter tops, and the fridge. Licensee will take a picture and email, mail or fax to LPA Hernandez Torres at:
elpidia.hernandez-torres@dss.ca.gov
1450 Neotomas ave suite 100 Santa Rosa CA 95405
Fax: 707-588-5099
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Based on interviews and evidence obtained licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3