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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:29:29 PM

Document Has Been Signed on 09/21/2023 04:29 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:PEREZ, EMILIO FCCHFACILITY NUMBER:
493009773
ADMINISTRATOR:EMILIO PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 230-1631
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
09/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maria Medina and Emilio PerezTIME COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA), Amy Strother conducted a Plan of Correction (POC) visit to the facility. Assistant, Maria Medina (A1) answered the door, inviting LPA inside. A1 stated that Licensee, Emilio Perez (L1) was not home. S1 and assistant S3 were providing care to 10 children, 4 infants (C1, C3, C6 and C7) and 6 preschool age children. During today's visit, beginning at 1:08pm LPA observed the following infant safe sleep violations. Infant C1 and C3 were observed sleeping in infant swings. Infant C7 was observed sleeping in a play yard, inside of the play yard, C7 slept on a loose play mat with a toy bar arched over head.

The purpose of the visit was to follow up on one Type A deficiency and eight Type B deficiencies that were cited on 08/29/23. L1 was cited a Type A deficiency based on assistant S2’s presence in the home providing care and supervision to the children without having S2’s criminal record clearance associated to L1’s facility. A review of records shows that S2's eligible clearance was associated the facility on 08/31/23. Based on interview with S1, S2 was not present in the facility on 08/30/23. The Type A deficiency has been cleared.

L1 was cited the following eight Type B deficiencies on 08/29/23: 1) L1 did not have documentation of a disaster drill conduct in the last 6 months on file. A review of L1's disaster log today shows the last drill conducted was on 09/09/23, clearing the deficiency. 2) Licensee was not present in the home during the visit on 08/29/23 and based on interview is absent from the home in excess of 20% of the hours that the facility is providing care per day. Based on L1's absence in the home during today's visit and interview with L1 when he arrived to the home at 1:20pm, L1 is absent from the home in excess of 20% of the hours that the facility operates, at least 3 days a week. L1 has failed to correct the deficiency. 3) L1 did not have proof of S1 completing the Mandated Reporter training. Based on interview with L1 and S1 during today's visit, S1 has not competed the Mandated Reporter training, failing to correct the deficiency. 4) No staff present on 08/29/23 had current pediatric first aid/CPR training certificates.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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
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: PEREZ, EMILIO FCCH
FACILITY NUMBER: 493009773
VISIT DATE: 09/21/2023
NARRATIVE
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 Based on today's interviews, S1 and S2, the only staff present when LPA arrived, do not have current certificates. 5)Staff (S3) did not have proof of immunity to Measles, Pertussis, influenza (or statement declining influenza vaccine) or a TB clearance on file. Based on file review during today's visit, S2 had proof of Pertussis on file, but did not have proof of immunity to Measles, flu or a TB clearance on file. 6) Five children C1-C5, did not have proof of required immunization's on file. A review of records indicates that C2 and C4 no longer attend the facility. A review of C1, C3 and C5's files indicates that they have current immunization's as required. 7) Licensee does not have proof of a liability insurance policy on file, therefore is required to have the authorized representatives of children enrolled sign form LIC282 Affidavit Regarding Liability Insurance for Family Child Care Homes, C1-C5 did not have form LIC282 on file. Today, form LIC282 was in C1, C3 and C5's files, and C2 and C4 no longer attend. 8) C1, an infant under 12 months did not have form LIC9227 Individual Infant Sleeping Plan on file as required. A review of C1's file during today's visit, showed a completed form LIC9227 on file.

The purpose of today’s POC visit is to clear the above Type A citation due 08/30/23 and the eight Type B citations, all with a due date of 09/19/23. LPA cleared the Type A Citation and confirmed that form LIC9224 was on file in children's files. LPA cleared 4 out of 8 of the Type B citations during today's visit. L1 did not meet the Plan of Correction for 4 out of 8 Type B citations.

In accordance with California Code of Regulations (CCR), 101195(f), the Department is assessing a Civil Penalty of $100 per day for period of 09/20/2023 through 09/21/2023, for four Type B deficiencies at $200 each, for a total of $800. See forms LIC421FC for the Type B citations that have not been corrected.

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

Exit interview conducted and report reviewed with L1. 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. Appeal Rights were provided

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

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2023 04:29 PM - It Cannot Be Edited


Created By: Amy Strother On 09/21/2023 at 03:39 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: PEREZ, EMILIO FCCH
FACILITY NUMBER: 493009773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
102425(b)

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102425 Infant Safe Sleep(b)Cribs or play yards shall be free from all loose articles and objects.



This requirement is not met as evidenced by:
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L1 stated he will remove all loose objects from play yards used by infants. L1 will review the Infant Safe Sleep regulations along with his assistants submitting a signed statement from L1, S1 and S3 that they understand and will follow the regulations and submit to LPA at amy.strother@dss.ca.gov by 09/28/23.
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Based on observation, at 1:09pm LPA observed infant C7 sleeping in a play yard, inside of the play yard, C7 slept on a loose play mat with a toy bar arched over head, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/28/2023
Section Cited
CCR102425(i)

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102425 Infant Safe Sleep(i) 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:
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L1 stated that if an infant falls asleep in a swing or any other located other than a play yard they will be placed in the play yard. L1 will review the Infant Safe Sleep regulations along with his assistants submitting a signed statement from L1, S1 and S3 that they understand and will follow the regulations and submit to LPA at amy.strother@dss.ca.gov
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Based on observation,beginning at 1:08pm LPA observed infant C1 asleep in an infant swing in the living room and C3 was observed sleeping in infant swing in the bedroom, 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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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