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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010050
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:23:19 PM

Document Has Been Signed on 04/25/2024 12:23 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:PAYNE, JESSICA FCCHFACILITY NUMBER:
483010050
ADMINISTRATOR/
DIRECTOR:		PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 14TOTAL ENROLLED CHILDREN: 21CENSUS: 8DATE:
04/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Licensee Jessica PayneTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elpidia Hernandez Torres arrived to the facility to conduct a plan of correction visit. Licensee was previously issued three deficiencies on 04/10/2024: one type A for operating out of ratio, and two type B deficiencies; one for incomplete children's files, and the other for assistant (A1) not associated to the facility.

LPA arrived to the home on 04/25/2024 at 09:50AM, assistant (A2) was present alone providing care and supervision for 8 children (C1-C8), ranging from 14 months- 3 years old. None of the children present were 6 years old, none of the children present are enrolled and attending Elementary school including TK or Kindergarten. Licensee did not correct outstanding deficiency from 04/10/2024. As a result civil penalty of $100 is being issued on the attached LIC 421FC.

LPA reviewed the California Code of Regulations section 102416.5 (3), which states "If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c)." LPA also reviewed the Family Child Care Home Ratio sheet which is a visual of the amount of children, and age of children allowed to be under the care and supervision of an assistant when licensee is temporarily absent from the home.

At 11:03AM LPA reviewed children's records for children present, all children in care had all emergency information on file, blue CDPH 286 immunization card with all immunizations, clearing the first type B deficiency issued on 04/10/2024. Licensee Associated A1 on 04/17/2024, clearing the second type B deficiency issued on 04/10/2024.

LPA reviewed decision and order that was issued on 04/25/2024, for A1. A1 ". . .is prohibited from employment in, presence in, and contact with clients of, any facility licensed by the Department. . .". License maybe subject to deficiencies and fines if decision and order is violated.

This report was reviewed and verified with the licensee. Licensee was given a copy of this report. Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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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