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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010050
Report Date: 08/16/2022
Date Signed: 08/30/2022 07:16:06 PM

Document Has Been Signed on 08/30/2022 07:16 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:PAYNE, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 655-6210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 14TOTAL ENROLLED CHILDREN: 21CENSUS: 10DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Licensee Jessica PayneTIME COMPLETED:
05:57 PM
NARRATIVE
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A an annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. A review of staff records on 08/15/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee and spouse were supervising 10 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 24 hours Sunday through Saturday. Licensee understands 24 hour consecutive care is prohibited. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the back and side yards, the garage, and all four bedrooms and were made inaccessible by door locking mechanisms and child safety gates. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification which expire in 2024 and AB 1207 which expires in 2023. Licensee was not able to furnish a disaster drill log a deficiency was cited. Parents rights poster was not posted a deficiency was cited. Licensee was not able to furnish LIC 9040 facility roster a deficiency was cited. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Licensee stated poisons are not stored on the premises. The regulation that poisons are to be locked with a key or combination lock was reviewed. The fireplace has been made inaccessible with a safety screen. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. The licensee uses a local park as the outdoor play area. LPA observed an inflated able pool with standing water that did not have a fence surrounding it or cover. 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. Deficiency cited with immediate $500 civil penalty. Continued on 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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: 08/16/2022
NARRATIVE
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 Six children's records were reviewed; required emergency information was not observed to be on file a deficiency was cited. All children's files were missing required documentation a deficiency was cited. Infants were misising LIC 9227 and sleep logs, deficiencies were cited.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Jessica Payne.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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Document Has Been Signed on 08/30/2022 07:21 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/26/2022 10:14 AM


Created By: Elpidia Hernandez Torres On 08/16/2022 at 04:49 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
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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review licensee was not able to furnish log of a disaster drill completed. LPA could not verify the time or date the drill was conducted. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to conduct a disaster drill and document it. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check for completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
Type B
Section Cited
CCR
102417(g)(5)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review and observation the back yard was not Inaccessible, the slide door was able to be opened and children had accsess to the back yard where the inflatable pool was located with water in it. An immediate $500 Civil Penalty was issued. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to empty the pool and make the back yard inaccesible. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check for completion.
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: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


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Document Has Been Signed on 08/16/2022 06:27 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 08/16/2022 at 04:49 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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Licensee was not able to furnish sleep log documenting 15 min. checks. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to keep sleep log with times, date observation for each infant in care. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check to completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review Licensee did not have PUB 394 posted. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to post PUB 394. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check to completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
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: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2022 06:27 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 08/16/2022 at 04:49 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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) 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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Licensee was not able to furnish LIC 700 for children in care. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to keep LIC 700 for all children in care. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check for completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Licensee was not able to furnish receipte parents have received required documents. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to keep recipet guardians and authroized representatives have recieved required documents for children enrolled. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check for completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
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: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2022 06:27 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 08/16/2022 at 04:49 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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, Licensee was not able to furnish LIC 9040 facility roster. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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2
3
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Licensee has agreed to keep LIC 9040 facility roster for all children in care. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check for completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Licensee was not able to furnish LIC 9227 sleep plan for infant in care. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Licensee has agreed to complete LIC 9227 for each infant under 12 months in care. LPA Hernandez Torres will come back to facility on or around 08/30/2022 to check to completion. Licensee understands if items are not completed a failure to correct civil penalty maybe assessed.
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: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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