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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010050
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:06:30 PM

Document Has Been Signed on 04/10/2024 04:06 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: 10DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Assistant A1TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Elpidia Hernandez Torres arrived to the Family child care home to deliver deficiencies. Licensee has assistant ( A1), who has been working at the family child care home over 30 days. A1 has back ground clearance but is not associated to the family child care home. Type B deficiency was issued. Civil penalty of $500 was issued.

LPA was previously at the facility on 03/25/2024, and attempted to review children's records for the children who were present. Licensee was not able to provide the required documentation for children present. LPA arrived to the home on 04/10/2024 to review children's records for the day care children present. There were Ten children present, eight ( C1-C8) of the ten children present are day care children. Six children (C1-C6) have been enrolled at the day care for over 30 days, and are missing all documents required to be in children's records. Type B deficiency was issued.

During LPAs visit, Licensee's assistants (A1-A2) were in the home with ten children. Licensee's assistant (A2) took two children at approximately 02:20PM, leaving A1 alone with eight children (C1-C8) raging in ages from 14 months- 5 years old. None of the children present were enrolled and attending school, none of the children present were 6 years old. Type A deficiency is being issued on the attached 809-D.

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 A1. LPA Hernandez Torres informed A1 that this report dated 04/10/2024 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 Hernandez Torres informed A1 to provide a copy of this licensing report dated 04/10/2024 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: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/10/2024 04:06 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 04/10/2024 at 12:35 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: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
102370(d)(2)

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(d) All individuals. . . prior to working, residing, or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance. . .
This was not met as evidence by. . .
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LPA will return on or before 04/17/2024 to verify all staff present on associated to the facility.
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Based on interview and record review, assistant (A1) has been working at the Family Child Care Home for over 30 days and is not associated to the facility. This poses a potential health and safety risk to children in care.
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Type B
04/17/2024
Section Cited
CCR102417(g)(7)

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102417 Operation of a Family Child Care Home. . . 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 was not met as evidence by. . .
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LPA Hernandez Torres will return on or before 04/17/2024 to verify licensee began to collect all required documents for children in care.
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Based on interview and record review children C1-C6 were missing all required enrollment documents. This poses a potential health and safety risk to 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:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/10/2024 04:06 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 04/10/2024 at 02:32 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: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2024
Section Cited
CCR
102416.5(e)

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102416.5 Staffing Ratio and Capacity,(e)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). This was not met as evidence by. . .
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LPA will return for a POC visit on or before 04/17/2024 to verify all children present in care have for LIC 9224 in their file and to verify the number of children present with staff/ assistants.
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Based on observation, while LPA was present Licensee's assistant was left alone with 8 children ranging in ages from 14 months- 5 years old. This poses an immediate health and safety risk to 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:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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