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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009685
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:20:50 PM

Document Has Been Signed on 01/03/2025 12:20 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: 4DATE:
01/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Carolyn SimonsTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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During today’s unannounced visit to the facility, LPAs Amy Strother and M. Mohr observed L1 and an assistant (S1) supervising 4 children,(2 preschool age children, C2 & C3 and 2 infants, C4 & C6), later joined by co-licensee, Richard Simons (L2).

At 10:44am L1, L2 and S1 went outside supervising 3 children with the door to the patio closed while infant C6 was asleep inside of the home. L1 returned in the home at 10:46am, walked into the laundry room, closing the door and returned to the homes main living area at 10:48am. Between 10:44am and 10:48am no provider was physically close enough to hear infant C6 wake up. L1 and S1 stated that they have audio devices in their ears to hear C6. LPA Strother reminded L1 and S1 that although they can use audio or video monitoring devices it shall not be in place of the requirement to be physically close enough to hear.

During the visit, LPAs requested to review C6’s file. Based on file review C6’s file did not contain the following forms: LIC9227, LIC700, LIC627 and LIC995A.

The following violation of the California Code of Regulations, Title 22, were observed during today’s visit. See LIC809-D. Appeal Rights were provided.

Exit interview conducted and report was reviewed with licensee, Carolyn Simons.

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: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 3
Document Has Been Signed on 01/03/2025 12:20 PM - It Cannot Be Edited


Created By: Amy Strother On 01/03/2025 at 11:40 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: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
102425(j)(7)

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(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (7) A digital video and audio monitoring device may be used in the home but shall not be used in place of the requirements enumerated in subjection (j).

This requirement has not been met as evidenced by:
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L1 stated that one provider will be present and close physically hear the infant while sleeping. L1 will email LPA a written statement of her understanding of the requirement by 01/31/25.
amy.strother@dss.ca.gov
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C6 was asleep in the home at 10:44am while all of the providers, L1, L2 and S1 were outside with the door closed supervising 3 other children. L1 and S1 stated that were using audio devices in their ears.
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Type B
01/31/2025
Section Cited
CCR102425(c)

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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:
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Licensee stated she would obtain a complete LIC9227 and send a copy to LPA Strother by email at amy.strother@dss.ca.gov by 01/31/25.
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Based on record review, the facility did not possess form LIC9227 Individual Infant Sleeping Plan for C6 which poses a potential health, safety or personal rights risk to persons in care.
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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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/03/2025 12:20 PM - It Cannot Be Edited


Created By: Amy Strother On 01/03/2025 at 11:44 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: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
102417(g)(7)

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement has not been met as evidenced by:
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L1 stated that she will obtain forms LIC700, LIC627 and LIC995A for child C6, sending to LPA Strother by 01/31/25.
amy.strother@dss.ca.gov
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Based on file review and interview, the licensee did not comply with the section cited above. C6’s file did not contain forms LIC700, LIC627 and LIC995A, which poses a potential health, safety or personal rights risk to persons in care.
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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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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