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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009674
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:34:01 PM

Document Has Been Signed on 11/30/2022 03:34 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:MULDER, TONYA FCCHFACILITY NUMBER:
493009674
ADMINISTRATOR:MULDER, TONYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 857-6563
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Tonya MulderTIME COMPLETED:
03:45 PM
NARRATIVE
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Licensee, Tonya Mulder. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received 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, 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.

During the inspection the home was toured inside and outside. Licensee was supervising 8 children without an assistant present during today's inspection. 7 of the 8 children in care were preschool age (not 6 or enrolled in and attending kindergarten) and 1 of the 8 children was an infant, age 17 month. Licensee was operating over capacity without an assistant present. The facility’s operating hours are Monday - Friday 6:00am - 6:00pm. The floor plan submitted by the licensee was reviewed and verified. Bedroom #1, bedroom #2 and garage are off limits to the children. The off-limits areas are made inaccessible by door locks. The home was observed to be clean and orderly, and at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire on 11/2024. LPA observed slug and snail killer under the unlocked kitchen sink and cleaners stored in the hallway bathroom, unlocked under the sink. Licensee has been advised that cleaners must be made inaccessible by a child safety latch on cupboard or stored up high enough that they can not be reached by children. Licensee moved cleaners and poison to an inaccessible cupboard. Licensee has been advised that poisons, must be under lock and key or combination lock. LPA observed a working smoke detector and carbon monoxide detector. LPA observed several fire extinguisher rated 1A10BC in the home and one extinguisher rated 2BC. Licensee did not have an extinguisher rated at least 2A10BC in the home, as required.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 11/30/2022 03:34 PM - It Cannot Be Edited


Created By: Amy Strother On 11/30/2022 at 01:30 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: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 under sink storage areas that were accessible to children. LPA observed slug and snail killer under the unlocked kitchen sink cupboard and cleaners stored were observed to be stored in the hallway bathroom under the sink without a child safety lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Licensee put cleaners in high cupboards inaccessible to children during the inspection and stated that she will continue to store them there. Licensee stated she will install a key lock door knob on the laundry room door, keeping all poisons stored in the laundry room with the door locked, only accessible with a key.
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two out of the 8 children present. Licensee was supervising 8 children without an assistant present during today's inspection. 7 of the 8 children in care were preschool age (not age 6 or enrolled in and attending kindergarten) and 1 of the 8 children was an infant age 17 month, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Licensee stated that her assistant will be present from now on, anytime she has more than 6 children in care, unless the 7th and 8th child are at least 6 years old and one enrolled in and attending kindergarten (operating as a small Family Child Care Home). Licensee stated that she needs her assistant present on Tuesday, Wednesday and Friday, but not Monday and Thursday based on the current schedules of the children currently enrolled.
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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 03:34 PM - It Cannot Be Edited


Created By: Amy Strother On 11/30/2022 at 01:30 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: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee had several fire extinguishers on site, all which were rated 1-A:10-B:C, when asked, Licensee stated she did not have an extinguisher rated 2-A:10-B:C as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee stated that she will obtain a fire extinguisher rated at least 2A10BC and submit a photo of the extinguisher to LPA Strother by 12/07/22.
amy.strother@dss.ca.gov
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 5 children's files. When asked if Licensee had immunization records for Child 1 (C1) and Child 4-5 (C4-C5), she stated she did not have the records available or have a completed CDPH 286 for C1, C4 and C5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2022
Plan of Correction
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Licensee obtained complete immunization records for C1, and transcribed the vaccines onto the CDPH286 during today's visit. Licensee stated she will obtain complete immunization records for C4 and C5, and submit them to LPA, along with the the completed CDPH286 to LPA by 12/21/22.
amy.strother@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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


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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: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674
VISIT DATE: 11/30/2022
NARRATIVE
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 The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 07/01/2022. Licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The children use the front yard and backyard for outdoor play. The backyard is fully fenced. Licensee understands that when children play in the unfenced front yard, they must be supervised at all times. Five children's records were reviewed. Licensee did not have immunization records on file for 3 out of the 5 children's files reviewed. Child 1 (C1) and Child 4 & 5 (C4-C5) did not have immunizations records on file. Facility and personnel files were reviewed and contained required records.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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.

Exit interview conducted and report was reviewed with the licensee, Tonya Mulder.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

LPA Strother informed licensee Tonya Mulder that this report dated 11/30/22 documents two Type A citations. Type A citations shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674
VISIT DATE: 11/30/2022
NARRATIVE
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Also, LPA Strother informed the licensee to provide a copy of this licensing report dated 11/30/22 that documents any Type A citations 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.

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: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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