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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009674
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:53:28 PM

Document Has Been Signed on 11/14/2024 02:53 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MULDER, TONYA FCCHFACILITY NUMBER:
493009674
ADMINISTRATOR/
DIRECTOR:		MULDER, TONYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 857-6563
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Tonya MulderTIME VISIT/
INSPECTION COMPLETED:
03:08 PM
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An annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Licensee, Tonya Mulder (L1). L1 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.

During the inspection the home was toured inside and outside. During today’s visit L1 was operating as a small family childcare home and was supervising five children (2 infants and 3 preschool age children) and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday - Friday 6:00am - 5:00pm. L1 provided a current roster of children in care as required. LPA verified that the children present were listed on the roster. The floor plan submitted by the licensee was reviewed and verified. Bedroom #1, bedroom #2, the laundry room 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 was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated that poisons are stored in the key locked laundry room. LPA verified that the door to the laundry room was locked during today's inspection. The facility family room has a fireplace which is barricaded with a child safety gate. LPA observed a working smoke detector, carbon monoxide detector and a fire extinguisher that appeared to charged and rated at least 2A10BC, in the home. The licensee has conducted an emergency drill within the past six months; last drill was documented on 08/09/24. The 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 backyard for outdoor play.

Continued on LIC 809-C

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674
VISIT DATE: 11/14/2024
NARRATIVE
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The backyard is fully fenced. Five children's records (C1-C5) were reviewed. Children C1 and C2 were missing required immunization. L1 stated that she doesn't have the most current print out of any additional immunizations for C1 and C2. Infant, C3 is required to have a LIC9227 Individual Infant Sleeping Plan on file. At 12:02pm L1 stated that she does not have form LIC9227 for C3 and does not have Sleep Logs completed for infants C3 or C4. L1 started a Sleep Log for C4 during today's visit. 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 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/.

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

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Continue on LIC809-C

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MULDER, TONYA FCCH
FACILITY NUMBER: 493009674
VISIT DATE: 11/14/2024
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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.

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

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

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

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 11/14/2024 02:53 PM - It Cannot Be Edited


Created By: Amy Strother On 11/14/2024 at 02:02 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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 2 out of 5 children's files. Children C1 was missing VAR and HIB on or after their 1st birthday and C2 was missing the 4th Dtap from their files and form CDPH286, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee stated she will obtain updated print outs of immunization records from the authorized representatives of children C1 and C2 to have on file and update form CDPH286 for C1 and C2 by 11/22/24 and send print outs to LPA Strother via text message: (707)599-1479.
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, the licensee did not comply with the section cited above in one infant under 12 months file. Infant C3 did not have form LIC9227 on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee stated she will ask the authorized representative of infant C3 to fill out form LIC9227 and add it to C3's file, sending a photo of the completed LIC9227 to LPA Strother by text message by 11/22/24.
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:Megan Aviles
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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Document Has Been Signed on 11/14/2024 02:53 PM - It Cannot Be Edited


Created By: Amy Strother On 11/14/2024 at 02:02 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 two of two infant files. Licensee did not have sleep logs for infants, C3 and C4, including documentation of date, infant's name and the time of each 15-minute check, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee started a sleep log for C4 during today's visit and will start a sleep log for C3 when C3 takes their second nap today. Licensee will continue to document sleep logs containing C3 and C4's names, the date and the time of each check, each day that C3 and C4 nap while in care. Licensee will send photos of completed sleep logs from dates 11/14/24 - 11/21/24 to LPA Strother by text message on 11/22/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Megan Aviles
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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