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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010050
Report Date: 12/30/2024
Date Signed: 12/30/2024 05:01:43 PM

Document Has Been Signed on 12/30/2024 05:01 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: 18CENSUS: 12DATE:
12/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Licensee Jessica PayneTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Through the course of an investigation Licensing Program Analyst (LPA) Elpidia Hernandez Torres, reviewed sign in/out sheets from the local resource and referral agency subsidy program for the dates LPA was physically present in the facility. This program only provides sign in/out sheets for families who participate in the program. LPA reviewed the sign in/out sheets for; 07/12/24, 07/18/24, 09/04/24, and a portion of the sheets for; 10/10/24,10/15/24, 10/24/24. Of the sign in/out sheets reviewed for the days and times LPA was present in the facility, LPA identified the following:

-07/12/24- LPA shows a census of 2 children present from 03:00PM-04:00PM; sign in and out shows 22 children present in the home during the same time.

-07/18/24- LPA shows a census of 13 children present from 02:25PM- 02:50PM; sign in and out shows 18 children present during the same time.

-09/04/24, LPA shows a census of 5 children present from 10:00AM- 12:15PM. The sign in/out shows 5 children present but the five present do not match the children LPA documented as present. The sign in/out also shows a child ‘arrived’ at a later time, when they were present during LPA’s visit.

-10/10/24, LPA shows census of 5 kids present between 08:50AM- 10:10AM. According to sign in/ out only 2 children were present. Another child that was present while LPA was present is signed in as ‘arrived’ at a later time.

-10/15/24, LPA shows 9 children present between 11:45AM- 01:00PM, 3 children present while LPA was present are documented in-accurately on the sign in/out sheets.

-10/24/24, LPA shows 5 children present from 05:40PM-06:30PM; sign in/out sheet shows 9 children present during the same time.

Continued on 809-C

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PAYNE, JESSICA FCCH
FACILITY NUMBER: 483010050
VISIT DATE: 12/30/2024
NARRATIVE
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In addition, according to the subsidy program, there were a total of 33 children enrolled as of July, 2024 yet the LPA’s reports in July - December show a maximum of 21 children enrolled. Furthermore, the Licensee submitted 27 sign in/out sheets for August 2024 which showed 19 children present on 08/12/24.

Licensee confirmed the local resource and referral agency subsidy program notified her that she was overlapping in the number of children present between 03:00PM and 05:00PM during the month of August 2024 and that she had 10 days to terminate four families. Licensee rearranged the children’s schedules so there wouldn’t be overlapping. Licensee further stated she does not have written schedules with the families but does have a verbal agreement.

A guardian reported their child had not attended the day-care in months, but licensee was still getting paid through the local resource and referral, subsidy program to ‘hold’ the child’s spot. Licensee reported she fills out the sign in/out sheets and will ask assistant what time children arrived if they arrived while licensee was out. Licensee’s assistant reported they don’t ‘sign in’ children when they arrive, but instead licensee will text assistant when a guardian is on their way.

The following type A deficiency is being cited on the attached 809-D page Health and safety code 1596.885(c). 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. LPA Hernandez Torres informed licensee that this report dated 12/30/24 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to health and safety.

Also, LPA Hernandez Torres informed licensee to provide a copy of this licensing report dated 12/30/2024 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. This report was reviewed and discussed with licensee who was provided a copy of this report and Appeal Rights.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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Document Has Been Signed on 12/30/2024 05:01 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 12/30/2024 at 02:18 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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2024
Section Cited
HSC
1596.885(c)

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Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.
This requirement was not met as evidenced by. . .
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Licensee stated she will create a procedure to ensure all documents are accurately submitted and train all staff on the procedure. Within 24 hours, Licensee will submit the procedure to CCL.
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Based on Licensee submitting false documents to receive subsidy program funds by showing inaccurate time in and out entries on monthly records when children were found not to be in attendance. This poses an immediate health and safety risk.
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Licensee reported she has created a graph to visually see who is present and at what time. Licensee has agreed to submit a written plan in detail of how the graph works.

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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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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