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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009685
Report Date: 11/20/2025
Date Signed: 11/20/2025 12:00:41 PM

Document Has Been Signed on 11/20/2025 12:00 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: 3CENSUS: 2DATE:
11/20/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Carolyn & Richard SimonsTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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An annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother and Licensing Program Manager (LPM) Mindy Mohr. LPA and LPM met with Licensees, Carolyn & Richard Simons (L1 and L2). Licensees were 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 two infants and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday - Friday 7:15am - 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-limits areas of the home are the garage and detached structure in the backyard. During today's inspection the detached structure, labelled "Toddler Room" on the LIC999A facility sketch was not locked. L2 stated that the weather warped the door, making it unable to lock. L2 was able to lock the door during the inspection. There were safe toys and equipment available for children. There is a working telephone in the home (the licensee's cell phone). Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were not observed to be stored out of the reach of children. At 9:21am LPA observed a basket of over the counter medication, all of which appeared to be natural products. At least one of the products, "ColdCalm" was labelled "Keep out of reach of children." The basket was located on a low shelf located below the changing table in family room.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/20/2025 12:00 PM - It Cannot Be Edited


Created By: Amy Strother On 11/20/2025 at 10:59 AM
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: 11/20/2025

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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Based on observation, the licensee did not comply with the section cited above.a basket of over the counter medication, all of which appeared to be natural products. At least one of the products, "ColdCalm" label stated "Keep out of reach of children." The basket was located on a low shelf located below the changing table in family room. Two mobile infants were observed in the family room during today's inspection with access to the medication, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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Licensee will submit a statement of her understanding of the regulation and how to safely store medications. The statement will be emailed to LPA Strother at amy.strother@dss.ca.gov
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

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. At 9:23am LPA observed a netted dome attached to a play yard in the Master Bedroom. LPA asked L1 if the play yard is used by day care children. L1 stated yes, it is used by C2, an infant in care during today's inspection and also by a two year, not present, who is able to climb out otherwise, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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Licensee removed the netted dome from the play yard and put it in storage during today's visit. Licensee stated will submit a written statement of their understanding of the infant safe sleep regulations.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/20/2025 12:00 PM - It Cannot Be Edited


Created By: Amy Strother On 11/20/2025 at 10:59 AM
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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

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. At 10:29am LPA went over to the room infant C1 was sleeping in to check the condition of the sleeping environment. L1 had completed a safe sleep check at 10:24am. LPA observed the door to be slightly open, not wide enough to see the sleeping infant, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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Licensee will submit a written statement of L1 and L2 understanding of the infant safe sleep regulations. by 11/27/25 to email: amy.strother@dss.ca.gov
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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SIMONS, CAROLYN & RICHARD FCCH
FACILITY NUMBER: 493009685
VISIT DATE: 11/20/2025
NARRATIVE
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Two mobile infants were observed in the family room during today's inspection. At 9:23am LPA observed a netted dome attached to a play yard in the Master Bedroom. LPA asked L1 if the play yard is used by day care children. L1 stated yes, it is used by C2. LPA informed L1 that items can not be attached to the play yards. L1 asked, what am I supposed to do, I have a 2 year old that climbs out of it. LPA explained that when a child climbs out, she is to discontinue use of the equipment. During the tour of the home L2 stated that any poisons are locked in a cabinet in the garage. The facility family room has a gas fireplace which is barricaded. 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 07/16/25. Licensee L1 and L2 stated that firearms and ammunition are stored separately as required. LPA confirmed ammunition is locked separately within the locked gun safe. At 10:29am LPA went over to the room infant C1 was sleeping in to check the condition of the sleeping environment. L1 had completed a safe sleep check at 10:24am. LPA observed the door to be slightly open, not wide enough to see the sleeping infant. The children use the backyard for outdoor play. The backyard is fully fenced. Two children's records were reviewed. 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 and removing any 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/.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 11/20/2025
NARRATIVE
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PAGE 3

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 Carolyn Simons, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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 and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Carolyn Simons.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 11/20/2025 12:00 PM - It Cannot Be Edited


Created By: Amy Strother On 11/20/2025 at 11:09 AM
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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102371(a)
(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 observation and interview, the licensee did not comply with the section cited above in that the off-limits detached structure, labelled Toddler Room in the back yard, does not have a fire clearance for use was observed to be unlocked, which poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 11/27/2025
Plan of Correction
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Licensee stated that she will submit a statement of L1 and L2's understanding that the door to the Toddler Room must remain locked at all times during child care hours and how this will be accomplished, by 11/27/25 to email: amy.strother@dss.ca.gov
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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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