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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503608001
Report Date: 07/01/2021
Date Signed: 07/01/2021 11:52:49 AM

Document Has Been Signed on 07/01/2021 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:COLLINS, DENISEFACILITY NUMBER:
503608001
ADMINISTRATOR:COLLINS, DENISEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 577-1627
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Denise CollinsTIME COMPLETED:
12:00 PM
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On 07/1/21 Licensing Program Analyst (LPA), Jose Penate conducted an unannounced Annual Required Inspection and was met by Licensee, Denise Collins. Days and hours of operation are Monday - Friday 7:30AM – 5:00PM.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that hallway bathroom, daycare room, living room, kitchen, dining room, office and backyard are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by doors being locked. There is no swimming pool or other bodies of water on the premises. There are firearms and ammunition at this home, both are separated from one another locked and in a safe. No poisons were observed during the inspection.

There is a working fire extinguisher, smoke detector. Carbon monoxide detector was not available at the time of inspection, but licensee located detector and plugged it in. Licensee ensures to continue to leave detector powered on in the facility. The home has adequate heating and ventilation for safety and comfort. There are no stairs in this home. The home has working telephone service and LPA confirmed the phone number is (209) 577-1627.

There is one play pins/yards for infant in care, play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes but does not document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed by licensee, while asleep in the living room. Individual Infant Sleeping Plan is not completed for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Continued on LIC 809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: COLLINS, DENISE
FACILITY NUMBER: 503608001
VISIT DATE: 07/01/2021
NARRATIVE
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

Licensee does not have a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s pediatric CPR/First Aid is current and will expire 6/5/2023. Mandated Reporter has not been completed. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. Licensee does not maintain child files for each child, licensee adds siblings information to previous filled out documentation.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies are cited (See LIC 809-D).

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/01/2021 11:52 AM - It Cannot Be Edited


Created By: Jose Penate On 07/01/2021 at 10:23 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: COLLINS, DENISE
FACILITY NUMBER: 503608001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
102425(j)(1)

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The provider shall physically check on the infant every 15 minutes. This requirement was not met as evidenced during today's inspection of facility file review. (See 809-C for further). This poses a potential risk
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Licensee was provided with safe sleep resources and information on regulations/requirements. Licensee was provided with a sample log for documenting every 15 minute checks for infants. Licensee stated she
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to the health, safety, and personal rights of children in care.
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will complete and document checks by 7/16/2021, and submit proof to CCLD-Fresno Child Care by POC date.
Type B
07/23/2021
Section Cited
HSC1596.8662(b)(1)

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Mandated Reporter Training - On or before March 30, 2018..is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete and renew mandated reporter training every two years. from the initial mandated reporter training.
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Licensee agrees to complete the required Mandated Reporter Training and will submit proof to CCLD by the POC due date of 07/23/21.
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This requirement was not met as evidenced by: Licensee's Mandated Reporter Training was unable to be located. This posses a potential risk to the health, safety and/or personal rights of children 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:Duane Matsubara
LICENSING EVALUATOR NAME:Jose Penate
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2021 11:52 AM - It Cannot Be Edited


Created By: Jose Penate On 07/01/2021 at 10:28 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: COLLINS, DENISE
FACILITY NUMBER: 503608001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
102417(g)(8)

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Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement is not met as evidenced by observation and records review conducted during today’s inspection. Licensee was
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Licensee stated she shall send a current roster of children in care to the CCL office by 7/16/2021.
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unable to provide LPA with a current roster of children in care. This poses as a potential risk to the health, safety, or personal rights of children in care.
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Type B
07/16/2021
Section Cited
CCR102425(c)(1)(2)

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An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. This requirement is not met as
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Licensee stated she shall send a current Individual Infant Sleeping Plan for infants in care to the CCL office by 7/16/2021.
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evidenced by observation and record review conducted during today's inspection. Licensee was unabel to provide LPA with for LIC 9227 for child #1. This poses as a potential risk to the health, safety, or personal rights of children 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:Duane Matsubara
LICENSING EVALUATOR NAME:Jose Penate
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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