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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525407032
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:15:37 AM

Document Has Been Signed on 04/30/2024 11:15 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:CHASE, DOMINIQUE FAMILY CHILD CARE HOMEFACILITY NUMBER:
525407032
ADMINISTRATOR/
DIRECTOR:		CHASE, DOMINIQUEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 200-1165
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
04/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Domique Chase - Licesensee TIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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On 4/30/24 at 9:05am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Sydney Sims and Elizabeth Friese. At 9:45am the home was toured inside and outside. The licensee and assistant were supervising 6 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:15am to 4:30pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are all bedrooms and laundry room and were made inaccessible by baby gates and door knob covers. The children use the back yard as the outdoor play area and it is fully fenced. There is a above ground pool in the back yard.
5 children's records were reviewed at 9:10am. Two staff records were reviewed at 9:36am. There is currently one adult living in the home.

The following deficiencies were cited: Licensee has an above ground pool without a fence that meets title 22 regulations, Licensee did not have a file for child C5 review during record review at 9:10am, Licensee does not have current CPR or First aid Training, Licensee and S1 do not have current Mandated Reporter Training, Licensee is not maintaining Personnel file on S1, Individual infant safe sleep plan not on file for C5 (see LIC 809D):


SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 11:15 AM - It Cannot Be Edited


Created By: Sydney Sims On 04/30/2024 at 10:16 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(5)
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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one count of having an above ground pool with out proper title 22 fencing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Licensee will create a plan for either removing the pool or installing correct title 22 fencing and send copy of plan to LPA Sims by 5/1/24. Licensee will also have all parents with children enrolled at the facility sign LIC 9224 by next buissness day or next day child is in care. Licensee will also have parents who enroll to the facility for the next 12 months sign LIC 9224. Licensee will maintain all LIC 9224s in children's files.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2024 11:15 AM - It Cannot Be Edited


Created By: Sydney Sims On 04/30/2024 at 10:16 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in 2 counts of the Licensee and Assistant S1 not having current mandatated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee and assistant (S1) will complete CCL deprtment approved mandated reporter training and send copy of certificates to LPA Sims via email to sydney.sims@dss.ca.gov
Type B
Section Cited
CCR
102391(d)
Inspection Authority of the Department
(d) The licensee shall permit the Department to inspect, audit, and copy children's records or other family child care home records upon demand during normal business hours. Records may be removed if necessary for copying.

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, by Licensee not maintianing a record for C5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Licensee will obtain copy of C5's required documents and send copy of documents to LPA Sims via email by 5/14/24.
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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2024 11:15 AM - It Cannot Be Edited


Created By: Sydney Sims On 04/30/2024 at 10:16 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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, Licensee's CPR and first aid training is expired and S1 does not have CPR/ First Aid Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licenee's will complete a CCL department approve CPR and First aid training and send copy of completion certificate to LPA Sims via email to sydney.sims@dss.ca.gov by 5/30/24.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

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, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee will make employee file for S1 containing all CCL's required documents for employees and send copy of file to LPA Sims via email to sydney.sims@dss.ca.gov
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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2024 11:15 AM - It Cannot Be Edited


Created By: Sydney Sims On 04/30/2024 at 10:16 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

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
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Based on record review, the licensee did not comply with the section cited above, Licensee did not have individual infant safe sleep plan on file for C5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Liensee will obtain a individual infant safe sleep plan for C5 and send copy of plan to LPA Sims via email to sydney.sims@dss.ca.gov by 5/14/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032
VISIT DATE: 04/30/2024
NARRATIVE
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LPA Sydney Sims and Elizabeth Friese informed licensee Dominique Chase that this report dated 4/30/24 documents One Type A citation(s) which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Sims and Friese informed the licensee to provide a copy of this licensing report dated 4/30/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.



To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inforesources/community-care-licensing/inspection-process.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032
VISIT DATE: 04/30/2024
NARRATIVE
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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.

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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CHASE, DOMINIQUE FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407032
VISIT DATE: 04/30/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Dominique Chase, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Dominique Chase.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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