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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485408079
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:14:06 AM

Document Has Been Signed on 12/09/2024 11:14 AM - 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:VALENZUELA, MIREYA FAMILY CHILD CARE HOMEFACILITY NUMBER:
485408079
ADMINISTRATOR/
DIRECTOR:		VALENZUELA, MIREYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 770-5671
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
12/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Mireya Valenzuela - Licensee TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced follow up Plan of Correction (POC) visit and met with Licensee (LS), Mireya Valenzuela, to evaluate compliance with Title 22 regulations. During an Annual/Random inspection on 08/30/24, LS was cited one type A and 13 type B deficiencies which had since been cleared. LS was previously cited and issued an immediate $500 civil penalty for not complying with requirements of criminal record clearance, not complying with infant safe sleep, S1 did not take or have evidence of completion of AB 1207 Mandated Reporter and Emergency Medical Services Authority (EMSA) approved Pediatric Cardio Pulmonary Resuscitation (CPR) and First Aid training, missing staff and children records including missing Immunization Records (IR), evidence of negative Tuberculosis (TB) clearance for S1, missing facility roster of the children in care, did not conduct at least one emergency disaster drill within six months; and fee were not current

During today's, LPA counted eight children in the care of LS and one staff (S1). According to LS, one adult resided in the home, she currently had one child (C5) under 24 months old enrolled in care, and all staff and children's records were complete; and LS submitted evidence of a completed facility roster of the children currently enrolled in care. A review of department records revealed LS and S1 had an active criminal record clearance, and the facility fee were paid on 09/05/24 and the fee were current. LPA reviewed 12 children's (C1-C12) at 9:04am which revealed C4-C5 & C7-C12's records were incomplete. C4 was missing IR, C5's LIC 700 was not signed by child's authorized representative, missing LIC 627 and IR. C7 was missing IR, LIC 627 and blue CDPH 286. C8 was missing LIC 627 and LIC 9224, C9's LIC 700 was missing parent's signature, LIC 627 and IR were missing. C10's LIC 282 was not signed by parent and missing LIC 627, C11 was missing IR, and C12 was missing LIC 627 and 995A and IR was not transcribed on CDPH 286. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079
VISIT DATE: 12/09/2024
NARRATIVE
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LS's pediatric CPR/First Aid certification was current and staff records included current AB 1207 Mandated Reporter Training certificates and IRs and were current.

LPA discussed Technical Support Program (TSP) which is a non-enforcement program that consists of on-site consultations visits, and during the visit, LS voluntarily agreed to participate in TSP to receive additional training, resources, and to address concerns in areas she felt were deficient. A previous licensing report was issued on 08/30/24 giving notice of the same violation, resulting in a repeat of the same violation within a 12-month period, and as such, a civil penalty of $250 was assessed for repeat violation.

Exit interview conducted and report was reviewed with the Licensee, Mireya Valenzuela. 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. The following violation of the California Code of Regulations, Title 22; Division 12, was observed during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2024 11:14 AM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 12/09/2024 at 10:33 AM
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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
102421(a)

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(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by: Based on twelve children's (C1-C12) records reviewed at 9:04am
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Licensee said she would provide the children's guardians with the required forms for them to complete, and Licensee intends to submit evidence of completed forms to the department by 12/13/24 via mail, email or fax.
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 which revealed C4-C5 & C7-C12's records were incomplete, and a civil penalty of $250 was assessed for repeat violation. 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.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

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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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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