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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009685
Report Date: 12/09/2024
Date Signed: 12/09/2024 06:22:56 PM

Document Has Been Signed on 12/09/2024 06:22 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:SIMONS, CAROLYN & RICHARD FCCHFACILITY NUMBER:
493009685
ADMINISTRATOR/
DIRECTOR:		SIMONS, CAROLYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 479-8714
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Carolyn SimonsTIME VISIT/
INSPECTION COMPLETED:
06:37 PM
NARRATIVE
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An annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Licensees, Carolyn & Richard Simons (L1 & L2). 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 and L2 were supervising 5 children and operating within the licensed capacity and ratio requirements. The parent (A1) of one child (C4) in care who lives in the home was also present. The facility’s operating hours are Monday - Friday 7:00am - 4:45pm. 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. The off-limit areas of the home are the garage, made inaccessible by a locked door. LPA reviewed the fire clearance on file, dated 01/30/24 that was denied based on the request to include the room addition ("toddler room") in the back yard. During an interview with L1 at 2:00pm, L1 stated that the toddler room in the back yard has been used by the children in care. 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 a combination locked cupboard in the garage. LPA verified that the poisons were locked. The facility family room has a gas fireplace which is barricaded with a glass door. L1 stated fireplace is not used. 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 11/05/24.

Continued on LIC 809-C

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
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)
Page: 1 of 8
Document Has Been Signed on 12/09/2024 06:22 PM - It Cannot Be Edited


Created By: Amy Strother On 12/09/2024 at 04:51 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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in one out of one infant (C4) in care. Licensee stated that C4 sleeps in an adult bed with C4's mom or on the bed alone or in a providers ares, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee stated that she will change the room C4 sleeps in to a room that is not C4's room and have C4 sleep in a play yard or crib beginning 12/10/24. L1 will submit a written statement with her plan for C4's sleeping environment.
Type B
Section Cited
CCR
102425(j)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. L1 stated that infant C4 sleeps in C4's room with the door closed with or without C4's parent present and is not supervised by a provider while sleeping, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee stated that she will begin observing C4 and all infants while sleeping beginning 12/10/24. L1 will provide LPA with a written statement on how she will comply with the regulation to supervise infants while sleeping.
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: 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)
Page: 2 of 8
Document Has Been Signed on 12/09/2024 06:22 PM - It Cannot Be Edited


Created By: Amy Strother On 12/09/2024 at 04:51 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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 files reviewed. Children C1, C4 and C5 did not have all of the required immunizations on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee stated that she will obtain immunizations for children C1 and C5 transcibing the records onto the CDPH286 form and send completed records to LPA Strother, amy.strother@dss.ca.gov by 12/16/24. L1 stated that she will work with C4's parent to obtain a medical exemption through, CAIR-ME, providing a statement from a doctor that the exemption will be granted by 12/16/24. L1 will provide a statement for an alternative plan, if a medical exemption is not granted for C4.
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 for one infant (C4) in care. L1 stated that she has not completed safe sleep logs to include date, name of infant and the time of each 15 minute check for C4, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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L1 stated she will begin Sleep Logs for infants in care on 12/10/24 and send copies of sleep logs to LPA on 12/16/24. 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:Megan Aviles
LICENSING EVALUATOR NAME:Amy Strother
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)
Page: 3 of 8
Document Has Been Signed on 12/09/2024 06:22 PM - It Cannot Be Edited


Created By: Amy Strother On 12/09/2024 at 04:51 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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

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 for two children in care (C2 and C3). C2 and C3, were observed to be sleeping in sleep sacks inside of play yards. L1 stated that C2 and C3 (both over the age of 2 years) are able to climb out of the play yard. Manufacturer instructions are to discontinue use when a child is able to climb out and when a child is 35 inches in height, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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L1 stated she will have C2 and C3 sleep on play mats in the living room beginning 12/10/24. L1 will provide a written statement that she understands that once children can climb out of play yard, she must dicontinue use for those children. Submitting the statement to LPA Strother's email
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: 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)
Page: 4 of 8
Document Has Been Signed on 12/09/2024 06:22 PM - It Cannot Be Edited


Created By: Amy Strother On 12/09/2024 at 04:56 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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102371(a)
102371 Fire Safety Clearance
(a) A fire safety clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal shall be required for a large family child 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. On 01/30/24 the facility's request for a fire clearance to add a room labelled "toddler room" to the approved area was denied. The toddler room is an unattached building located in the back yard. During an interview with Licensee (L1), L1 stated at 2:00pm that they have been using the room to provide care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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License locked the door to the "toddler room", stating that it will not be used until a fire clearance is granted. Licensee provided form LIC9054 and the facility sketch LIC999A to LPA during today's visit to request an updated and approved fire clearance that will not include the now marked "off limits" toddler room.
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: 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


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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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685
VISIT DATE: 12/09/2024
NARRATIVE
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PAGE 2

Licensee (L2) stated that firearms and ammunition are stored separately as required. The children use the covered porch and backyard for outdoor play, both are fully fenced. Five children's records were reviewed. Three out of five children's records (C1, C4 and C5) were missing required immunizations. The infant in care (C4) did not have sleep logs on file. L1 stated that she has not conducted sleep checks or completed the sleep log for infant C4 because C4 lives in the home and naps in bed with C4's mom who also lives in the home. L1 stated that C4 is enrolled, and although C4's parent is usually present, C4 is at times at the facility without a parent present. 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are 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: 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)
Page: 7 of 8
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: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685
VISIT DATE: 12/09/2024
NARRATIVE
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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 Carolyn Simons.

LPA Strother informed licensee Carolyn Simons that this report dated 12/09/24 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the licensee to provide a copy of this licensing report dated 12/09/24 that documents any Type A citation(s) 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.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
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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