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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009773
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:19:20 PM

Document Has Been Signed on 04/25/2024 01:19 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/
DIRECTOR:		EMILIO PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 230-1631
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 8DATE:
04/25/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Emilio PerezTIME VISIT/
INSPECTION COMPLETED:
01:25 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
A required inspection visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother. LPA met with Licensee, Emilio Perez (L1). Licensee 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 today’s visit, L1 and one assistant (S1) were supervising 8 children, 2 infants over one year of age (C1 and C2) and 6 preschool age children (C3-C8), operating within the licensed capacity and ratio requirements. L1 provided a current roster of children in care as required. LPA verified that all children present were listed on the roster. LPA requested to review sleep logs for infants C1 and C2. L1 provided a sleep logs with dates 02/12/24 – 02/22/24 for C1 and 02/22/24 – 03/06/24 for C2. When LPA requested more current sleep log dates for C1 and C2, L1 stated at 12:13pm that he must have lost them. At 12:31pm LPA observed infant C2 sleeping on their back in a Play Yard. LPA observed L1 visually check on C2 while sleeping and document a sleep check of C2 at 12:48pm. C2 woke up shortly after the 12:48pm check. C1 was not observed sleeping during the visit.

The following violation of the California Code of Regulations, Title 22; Division 12, was 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 licensee, Emilio Perez.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 01:19 PM - It Cannot Be Edited


Created By: Amy Strother On 04/25/2024 at 12:40 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
102425(j)(2)(D)

1
2
3
4
5
6
7
102425 Infant Safe Sleep (j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2)The provider shall check and document the following:(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
(Date, Infant’s name, Time of each 15-minute check)

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee began to document a sleep log for infant C2 while LPA was present. Licensee stated that he keeps track of the 15 minute checks by keeping a timer on his phone, checks on the infant(s) when the timer goes off, logs the sleep check, resets the timer and repeats. Licensee agreed to continue safe sleep logs for all infants, ages 0-24 months in care, stating he will file the logs in each infants file when the log is full. Licensee will email LPA copies of sleep logs for C1 and C2 on 05/03/2024 to amy.strother@dss.ca.gov.
8
9
10
11
12
13
14
Based on interview and record review, Licensee stated at 12:13pm that he did not have current sleep logs for infants C1 & C2 and must have lost them. A review of records indicated that the last sleep on file was dated 02/22/24 for C1 and 03/06/24 for C2. The licensee did not comply with the section cited above for two out of two infants present during the visit, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


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