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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
503911302
Report Date:
11/19/2021
Date Signed:
11/19/2021 05:33:51 PM
Document Has Been Signed on
11/19/2021 05:33 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
CCLD Regional Office
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
7
CENSUS:
5
DATE:
11/19/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:50 AM
MET WITH:
Sorense, Kim
TIME COMPLETED:
05:45 PM
NARRATIVE
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On 11/19/2021 Licensing Program Analyst (LPA), Roman Iglesias, conducted an unannounced Annual Required Inspection and was met by Licensee, Kim Sorensen. Also present was Staff #1 (S1). Days and hours of operation are Monday through Friday from 6:00 a.m. to 6:00 p.m.
LPA toured the home inside/outside and a census was taken. LPA also reviewed the current facility sketch and Licensee confirmed that the front bedroom, front restroom, family room, dining room, kitchen, and back yard are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of child safety gate. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.
The fireplace located in the living room is made inaccessible by a screen door and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector, and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (925) 337-7234.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at
https://www.cpsc.gov/
and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
(Continued on 809-C)
SUPERVISORS NAME
:
Alice Juarez
LICENSING EVALUATOR NAME
:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
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
9
Document Has Been Signed on
11/19/2021 05:33 PM
- It Cannot Be Edited
Created By:
Roman Iglesias
On
11/19/2021
at
03:09 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
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/19/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. The Licensee did not conduct fire drills/ disaster drills at least once every six months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2021
Plan of Correction
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3
4
Licensee stated she would be conducting a fire drill/ disaster drill and document it on or before 11/24/2021. Licensee mentioned she would mail proof of completion to CCL by 11/24/2021.
Type B
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation the licensee did not comply with the section cited above in that there was a walker in the front roomnwere infants sleep. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2021
Plan of Correction
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4
On this day, the Licensee removed the walker and placed it in a room not accessible to children in care. Licensee also wrote a document on this day, stating she understands that a walker is not allowed in a family child care home.
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:
Alice Juarez
LICENSING EVALUATOR NAME:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
11/19/2021 05:33 PM
- It Cannot Be Edited
Created By:
Roman Iglesias
On
11/19/2021
at
03:09 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
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/19/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
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:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. The play yard was not free from loose articles, objects, and blankets. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2021
Plan of Correction
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4
On this day, Licensee removed loose articles, objects, and blankets from the infants play yards. Licensee stated she will inform parents that children are not allowed to sleep with blankets. Additionally, Liceense wrote a statement stating she understands that play yards are to be free from loose articles, objects, and blankets.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. The provider was not physically checking on the infant every 15 minutes and was not documenting it, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2021
Plan of Correction
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4
On this day, Licensee began to physically check on the child and she doucmented the obervation. Licensee also wrote a statement stating she understands that she needs to physically check on children 24 months an under and document it.
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:
Alice Juarez
LICENSING EVALUATOR NAME:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
11/19/2021 05:33 PM
- It Cannot Be Edited
Created By:
Roman Iglesias
On
11/19/2021
at
03:09 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
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/19/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview the licensee did not comply with the section cited above. The door to the room were the infant was sleeping was closed and not open at all times. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2021
Plan of Correction
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On this day, Licensee opened the door where the infant sleeps. Licensee also wrote a statement stating she understands that the door is to remain open at all times while the infant is asleep.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above. Children's files were missing immunization records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/20/2021
Plan of Correction
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Licensee sent a text message to parents requesting immunization records for the children missing them. Licensee will also follow up with parents in person and provide proof of children's immunization records to CCL by 12/20/2021.
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:
Alice Juarez
LICENSING EVALUATOR NAME:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
11/19/2021 05:33 PM
- It Cannot Be Edited
Created By:
Roman Iglesias
On
11/19/2021
at
03:09 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
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/19/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as Licensee did not have a current roster of children as specified in Health and Safety Code, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/19/2021
Plan of Correction
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4
On this day, Licensee completed a child roster and wrote a statement indicating she understands the roster is to be kept current.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Children's files were missing a signed affidavit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/29/2021
Plan of Correction
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Licensee was provided with an LIC 282 (affidavit) form, and stated she would have parents fill it out. Licensee is to provide proof of completion to CCL by 11/29/2021.
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:
Alice Juarez
LICENSING EVALUATOR NAME:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
11/19/2021 05:33 PM
- It Cannot Be Edited
Created By:
Roman Iglesias
On
11/19/2021
at
03:09 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
,
1310 E. SHAW AVE,
FRESNO
,
CA
93710
FACILITY NAME:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/19/2021
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
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:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. The infant in care did not have an Individual Infant Sleeping Plan in his/her file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/29/2021
Plan of Correction
1
2
3
4
Licensee was provided with an Individual Infant Sleeping Plan and will have the infant's parents fill it out. Licensee also wrote a statement stating she understands that an Individual Infant Sleeping Plan is required for infants aged 0-12 months. Licensee is to provide proof of completed Individual Infant Sleeping Plan to CCL by 11/29/2021.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Alice Juarez
LICENSING EVALUATOR NAME:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
6
of
9
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:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
VISIT DATE:
11/19/2021
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. The outdoor play area in the backyard is fenced and there are no hazards to children present. There is one large dog. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets. Capacity as specified on the license is being maintained.
LPA reviewed a sample of children’s files and observed files were not completed as required. Licensee’s Mandated Reporter Training was completed on 03/11/2020. Licensee’s pediatric CPR/First Aid expires on 01/01/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.
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. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
Incidental Medical Services (IMS) are not currently being provided. IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at:
http://www.ada.gov/childqanda.htm
)
(Continued on 809-C)
SUPERVISORS NAME
:
Alice Juarez
LICENSING EVALUATOR NAME
:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
8
of
9
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:
SORENSEN, KIM FAMILY CHILD CARE
FACILITY NUMBER:
503911302
VISIT DATE:
11/19/2021
NARRATIVE
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32
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.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to
inspectionprocess@dss.ca.gov
. For additional information regarding the inspection and its tools and methods, please visit the
Program website
at
www.cdss.ca.gov/inforesourc
es/community-care-licensing/process
.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D)
Exit interview conducted and report was reviewed with the facility representative Kim Sorensen.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME
:
Alice Juarez
LICENSING EVALUATOR NAME
:
Roman Iglesias
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/19/2021
LIC809
(FAS) - (06/04)
Page:
9
of
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