<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:04:32 PM

Document Has Been Signed on 03/04/2024 12:04 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: 16CENSUS: 6DATE:
03/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Maria MedinaTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amy Strother made an unannounced follow up Plan of Correction (POC) inspection, in response to a type A deficiency that was cited on 02/28/24 due to the facility operating over ratio, with 7 infants in care. On 02/29/24 the Licensee submitted an updated roster of children in care and an email statement that 4 infants have been terminated from care, to meet the ratio requirements. During today’s visit, LPA Strother observed two assistants, S1 and S2 with 6 children in care (C1 – C6), four of which were infants (C1-C3 and C6), clearing the deficiency. LPA Strother reviewed signed form LIC9224 for each child C1-C6 in care today.

Upon arrival LPA met with assistant, Maria Medina (S1) who stated at 10:20am that Licensee Emilio Perez (L1) was not home and was currently on vacation today but will return tomorrow. LPA observed 5 children (C1 – C5) awake and in the front room upon arrival, and C6, an infant, sleeping in a play yard in the downstairs bedroom. At 10:25am LPA observed C6 asleep on her side, covered with a blanket. LPA requested that S1 remove the blanket from C6. S1 complied and removed the blanket. LPA asked S1 if C6 is able to roll from her back to her stomach and stomach to back. S1 stated that C6 is able to roll from her back to stomach and stomach to back.

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

Civil penalties were assessed for a repeat violations within 12 months (See LIC421FC). On 08/29/23 L1 was cited for being absent from the facility in exceedance of 20% of the hours that the facility is providing care per day. On 09/21/23 L1 was cited for loose objects observed in the play yard with a sleeping infant. The total about of today’s civil penalties total $500, $250 for each repeat violation. Appeal Rights were provided.

A notice of site visit was given to facility representative 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 facility representative Maria Medina.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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 2
Document Has Been Signed on 03/04/2024 12:04 PM - It Cannot Be Edited


Created By: Amy Strother On 03/04/2024 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: PEREZ, EMILIO FCCH
FACILITY NUMBER: 493009773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
102417(a)

1
2
3
4
5
6
7
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will return tomorrow. Licensee is requested to submit a written statement to LPA Strother at amy.strother@dss.ca.gov stating how the Licensee will meet the requirement for absences not to exceed 20 percent of the hours that the facility is providing care per day in the future.
8
9
10
11
12
13
14
Based on interview with S1, the licensee did not comply with the section cited above. Assistants S1 and S2 stated that Licensee is on vacation and has not been present today and will not be present during the hours of operation today, which poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/08/2024
Section Cited
CCR102425(b)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Based on observation, at 10:25am LPA observed infant C6 sleeping in a play yard covered with a blanket.
8
9
10
11
12
13
14
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: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2