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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483010050
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:33:49 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
08/27/2024 and conducted by Evaluator Elpidia Hernandez Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240827124617
FACILITY NAME:PAYNE, JESSICA FCCHFACILITY NUMBER:
483010050
ADMINISTRATOR:PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:14CENSUS: 5DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee's assistantTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Licensee transports children without appropriate vehicle restraint.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Elpidia Hernandez Torres, conducted a subsequent complaint investigation inspection on 12/05/24 at 11:00AM for the purpose of delivering the findings regarding the above allegation. LPA previously met with Licensee on 09/04/24,10/24/24, and 11/25/24 to discuss the purpose of the visit and request facility roster (LIC 9040), and Staff contact information. It was alleged that licensee transports children without appropriate vehicle restraint.

During the course of the investigation, interviews were conducted with licensee, assistant, 6 children, and 5 guardians between 09/04/24-12/03/24. Licensee reported she uses a 12 passenger van for transportation, and to conduct pick ups/ drop offs. Licensee also reported most of the children are able to buckle themselves, with the exception of younger children who can’t. For the older children licensee will hear the buckle click as an indication the seat is belt is fastened. Assistant reported there was at least one occasion where they helped younger children unbuckle from their car seats. Guardian interviews were uncertain if children were wearing seatbelts as they weren’t present at the time licensee is transporting children.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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-20240827124617
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: 12/05/2024
NARRATIVE
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Children interviews informed, on at least three occasions children were in the vehicle not wearing seat belts. On at least two occasions children were observed sitting on the floor of the van, and/or on the laps of other children. In addition, on one occasion the child that was observed sitting on the floor almost fell out of the van when licensee opened the door. One child reported there was one occasion all car seats were taken out of the van to accommodate space for adults sitting in the van which led to children sitting on the laps of other children. Children confirmed children sit on the floor or on the laps of other children when there is no room on the seats of the van.

Based on interviews conducted 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 102417(k) is being cited on attached LIC 9099D. This report was reviewed with licensee’s assistant and an exit interview was conducted. This Complaint Investigation Report (CIR), and Appeal rights were provided.

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’s assistant that this report dated 12/05/2024 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 licensee’s assistant to provide a copy of this licensing report dated 12/05/2024 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: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20240827124617
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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
102417(k)
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102417 Operation of a Family Child Care Home. (k) All vehicle occupants must be secured in an appropriate restraint system. This was not met as evidence by. . .
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Licensee wasn't present at the time of findings being delivered. Licensee's assistant agreed to the following plan; When children get in the van, licensee will check each individual child's seat belt before driving to ensure their seat belts are buckled.
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based on children's interviews there were at least three occasions were children were not wearing their seat belts, and sitting on other children's laps and/or on the floor of the van. This poses an immediate health and safety risk to children in care.
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Licensee will also only transport children for the number of seats available in the van. Licensee will self-certify plan of correction on form LIC 9098.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3