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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485408096
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:04:37 PM

Document Has Been Signed on 06/21/2024 04:04 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:SCZEPANSKI, LACY FAMILY CHILD CARE HOMEFACILITY NUMBER:
485408096
ADMINISTRATOR/
DIRECTOR:		SCZEPANSKI, LACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 628-8925
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
06/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Sheila Rose - Facility Representative TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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An Annual/Random inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 06/21/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Facility Representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. According to the Facility Representative, the facility was registered with the Resource and Referral Agency's, Food Program.


During today’s inspection, the home and grounds were toured. The Facility Representative and one staff were supervising nine children and the facility was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30am to 5:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are four bedrooms and two bathrooms on the second floor, one bedroom and one bath, and garage. These areas have been made inaccessible by means of children’s safety gates and child safety latches. The children have access to the family and dining areas, kitchen, half bathroom, and backyard. Cleaning compounds and medications were inaccessible. The home was at a comfortable indoor temperature. There were safe toys available for children. The fireplace was screened and not being utilized. There is a working telephone in the home and the Licensee understood that the facility telephone was required to stay at the facility during operating hours. Facility Representative EMSA approved pediatric CPR/First Aid certification expire 03/21/2026. LPA did not observe any poison(s). (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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: SCZEPANSKI, LACY FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408096
VISIT DATE: 06/21/2024
NARRATIVE
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There is a functional smoke and carbon monoxide detectors, and a fully charged fire extinguisher that met the standards of the state fire marshal. The facility did not have any bodies of water.

The facility representative said the facility conducted an emergency disaster drill in the middle of May 2024, however; there was no evidence to support that at least one disaster drill was conducted within six months. The facility roster of the children in care was reviewed and appeared to be complete. LPA reviewed five staff (LS & S1-S4) records at 12:44pm which revealed LS, S2 and S4 were missing evidence of completion of current AB 1207 Mandated Reporter Training, S1 was missing proof of immunity against Measles, S2 was missing evidence of negative TB clearance and Influenza, and S3 was missing proof of immunity against Measles and Influenza.



LPA reviewed five children’s (C1-C5) records at 1:34pm which revealed that the records contained contracts, Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information (LIC 700), Parents Rights (LIC 955A), Immunization Records (IR) and IR were transcribed onto the blue CDPH 286. Furthermore, the facility furnished evidence of purchased childcare liability insurance.

Facility Representative confirmed there were four children including C1 & C2, that were under 24 months old enrolled in care, and the Facility Representative did not furnish evidence to prove 15 minute checks had/were conducted while the four infants took a nap.

LPA discussed the safe sleep regulations with Facility Representative 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 Facility Representative 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.

(Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
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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: SCZEPANSKI, LACY FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408096
VISIT DATE: 06/21/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview conducted and report was reviewed with the Facility Representative, Sheila Rose. 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 violations of California Code of Regulations, Title 22; Division 12, were observed during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/21/2024 04:04 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/21/2024 at 02:21 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: SCZEPANSKI, LACY FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Facility Representative not furnishing evidence to prove at least one disaster drill was conducted within six months. 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: 07/01/2024
Plan of Correction
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Facility Representative said would conduct an emergency disaster drill, document the drill and submit an updated drill log with completed LIC 9098 to the Department by 07/01/24. Representative intends to submit POC to the Department by 07/01/24 via mail, email ro fax.

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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


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Document Has Been Signed on 06/21/2024 04:04 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/21/2024 at 02:21 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: SCZEPANSKI, LACY FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

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 the facility not furnishing evidence to prove fours infants were being checked every 15 minutes while they took a nap. 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: 07/01/2024
Plan of Correction
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Facility Representative said she would document at least five days worth of 15 minute checks on a sleep log, and the representative intends to submit evidence and completed LIC 9098 to prove the checks were conducted. POC will be submitted by 07/01/24.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on five staff (LS, S1-S4) records reviewed which revealed LS, S2 & S4 were missing evidence of completion of AB 1207 Mandated Reporter Training. 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: 07/01/2024
Plan of Correction
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Facility Representative said she would ensure all staff completed online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and facility representative intends to submit evidence of completion of training to the Department by 07/01/24 via email: melchisedeck.augustin@dss.ca.gov
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2024 04:04 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/21/2024 at 02:21 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: SCZEPANSKI, LACY FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on five staff (LS & S1-S4) records reviewed which revealed S1-S3 were missing required staff Immunization Records. 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: 07/01/2024
Plan of Correction
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Facility Representative said she would ensure all S1-S3 obtained evidence of their required Immunization Records, and facility representative intends to submit evidence of required records to the Department by 07/01/24 via mail, email or fax. Fax: 707-588-5099
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on five staff (LS & S1-S4) records reviewed which revealed S2 was missing evidence of negative TB clearance. 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: 07/01/2024
Plan of Correction
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The facility representative said she would have a discussion with S2 and ensure S2 obtained evidence of negative TB clearance, and the Representative said she would submit S2's evidence of negative TB clearance to the Department by 07/01/24.
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


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