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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008329
Report Date: 08/02/2024
Date Signed: 08/07/2024 09:09:29 AM

Document Has Been Signed on 08/07/2024 09:09 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HARTLEY, LISA FCCHFACILITY NUMBER:
493008329
ADMINISTRATOR/
DIRECTOR:		HARTLEY, LISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 539-5028
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
08/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:03 PM
MET WITH:Vivian Marcela Rocha PereiraTIME VISIT/
INSPECTION COMPLETED:
04:06 PM
NARRATIVE
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A Required Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 8/2/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee 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.

LPA was unable to complete the inspection on 8/2/24 and will return to complete the inspection at a later date. During today’s inspection the home and grounds were toured. The Licensee was not present in the home during the time of the inspection. Licensee is being cited separately under complaint report dated 08/02/24. Two assistants, facility representative Vivian Marcela Rocha Pereira (S1) and staff 2 (S2) were present in the home, supervising 7 children and were operating within the licensed capacity and ratio requirements. LPA called the Licensee who stated that she had left the facility at 11:00 AM that morning and would return on Monday, 8/5/24. No children were observed left in any parked vehicles. The facility’s operating hours are 8:00 AM to 5:00 PM, Mon–Fri. The home was at a comfortable indoor temperature. The children in care have access to age-appropriate toys and equipment. There is a working telephone in the home. Facility representative's pediatric CPR/First Aid certification was current and expires in October 2024. LPA observed a functioning smoke alarm, carbon monoxide detector and a fully charged fire extinguisher rated at least 2A10BC. At 12:47 PM, LPA observed that the retractable baby gate in the hallway was retracted and that just beyond the baby gate, the laundry door was a ajar and cleaning chemicals were stored low to the ground, accessible to children.


Continue to LIC 809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HARTLEY, LISA FCCH
FACILITY NUMBER: 493008329
VISIT DATE: 08/02/2024
NARRATIVE
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The facility did not possess a record of any emergency disaster drill conducted within the last six months. The facility roster of the children in care was reviewed which revealed that child 1 (C1) and child 2's (C2) information was not recorded. At 12:44 PM Facility representative (S2) stated that C1 and C2 share the same play pen to sleep in because they have different sleep schedules. At 1:26 PM S2 stated that the facility does not perform 15 minute sleep checks on infants, they only use baby monitors to listen to them. LPA reviewed staff and personnel records at 1:29 PM which revealed that staff 1 (S1) and staff 2 (S2) did not possess a current mandated reporter certification. LPA reviewed five children's records (C1-C5) at 1:46 PM which revealed that child 1, 2, and 3 (C1, C2, and C3) did not possess sleep logs to record sleep checks, C1 and C2 did not possess LIC9227 Individual Infant Sleeping Plans, C3's immunization record was missing a second required dose of Hepatitis B immunization, and child 4 (C4) was missing their PM 286 Immunization Record.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. Exit interview conducted and report was reviewed with Facility Representative Vivian Marcela Rocha Pereira. 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.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 08/07/2024 09:09 AM - It Cannot Be Edited


Created By: Robert Maciel On 08/02/2024 at 02:47 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: HARTLEY, LISA FCCH
FACILITY NUMBER: 493008329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, LPA observed accessible cleaning chemicals in the laundry room poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Facility representative stated that she would ensure the retractable baby gate that blocks the hallway is always up when children are present.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 08/07/2024 09:09 AM - It Cannot Be Edited


Created By: Robert Maciel On 08/02/2024 at 02:47 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: HARTLEY, LISA FCCH
FACILITY NUMBER: 493008329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

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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4
Based on record review, the licensee did not posses record of any disaster drill performed within the last 6 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Facility representative stated she would perform a disaster drill, record it onto a log, and send a copy of the log to LPA by email at robert.maciel@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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 08/07/2024 09:09 AM - It Cannot Be Edited


Created By: Robert Maciel On 08/02/2024 at 02:47 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: HARTLEY, LISA FCCH
FACILITY NUMBER: 493008329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(6)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (6) Each infant's bedding shall be used for him/her only. Bedding that touches the infant’s skin shall be cleaned at least weekly or before use by another infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, facility representative (S2) stated that C1 and C2 share the same play pen to sleep in because they have different sleep schedules which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Facility representative stated she would use the extra play pens so each infant can sleep in their own play pen.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, facility representative (S2) stated that she did not perform 15 minute sleep checks on sleeping infants, only utilizing a baby monitor device to listen to them which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Facility representative stated she would begin perfoming 15 minute sleep checks on infants and send LPA a copy of a week's worth of sleep logs for infants in care by email at robert.maciel@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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 08/07/2024 09:09 AM - It Cannot Be Edited


Created By: Robert Maciel On 08/02/2024 at 02:47 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: HARTLEY, LISA FCCH
FACILITY NUMBER: 493008329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
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Based on record review, staff 1 (S1) and staff 2 (S2) did not possess a current mandated reporter certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
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Facility representative stated that she would obtain current mandated reporter training certificates for herself and S2 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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
1
2
3
4
Based on review, child 1 (C1) and child 2 (C2) did not possess LIC9227 Individual Infant Sleeping Plans which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Facility representative stated she would complete LIC9227 Individual Infant Sleeping Plans for C1 and C2 and send a copy toLPA by email at robert.maciel@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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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