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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585405125
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:06:59 PM

Document Has Been Signed on 11/06/2024 12:06 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SIETSEMA, MARY FAMILY CHILD CARE HOMEFACILITY NUMBER:
585405125
ADMINISTRATOR/
DIRECTOR:		SIETSEMA, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 329-8658
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/06/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:07 AM
MET WITH:Mary SietsemaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 11/6/24 at 10:07am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Tammy Dutra. At 10:50am the home was toured inside and outside. The licensee was supervising three children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:00am- 5:45am, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the master bedroom, bedroom 2, bedroom 3, the office, the kitchen and the garage, and were made inaccessible by baby gate and child door knob covers. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

Three children's records were reviewed at 10:13am. One staff record was reviewed at 10:27am. There are currently two adults living in the home.

The following deficiencies were cited: during record review it was observed two children were missing immunization records or updated immunizations per regulations, one child is missing LIC 9227, individual infant sleep plan and 15 min sleep checks missing for infant in care. (see LIC 809D):

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 12:06 PM - It Cannot Be Edited


Created By: Tammy Dutra On 11/06/2024 at 11:05 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: SIETSEMA, MARY FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files missing immunizations or updated immunizations for age of children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
3
4
Licensee agrees to get updated immunization records and check with immunization tool to ensure children have correct immunizations for children in care by 11/15/24. Send documents to LPA at tammy.dutra@dss.ca.gov or text to cell phone at (530) 806-3471.
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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2
3
4
Based on record review the licensee did not comply with the section cited above in C2 was missing an LIC 9227, Individual infant sleep plan for a child in care under 12 months of age which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
3
4
Licensee agrees to have the parent or guardian of C2 sign an LIC 9227, Individual infant sleep plan by 11/15/24. Send document to LPA at tammy.dutra@dss.ca.gov or text to cell phone at (530) 806-3471.
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:Erin Virrueta
LICENSING EVALUATOR NAME:Tammy Dutra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 12:06 PM - It Cannot Be Edited


Created By: Tammy Dutra On 11/06/2024 at 11:05 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: SIETSEMA, MARY FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in C2 is missing 15 min sleep checks for infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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3
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Licensee agrees to begin documenting 15 min safe sleep checks for infant in care and send a copy of the checks to LPA by 11/15/24. Send sleep chart to LPA at tammy.dutra@dss.ca.gov or text copy to (530) 806-3471.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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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:Erin Virrueta
LICENSING EVALUATOR NAME:Tammy Dutra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


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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: SIETSEMA, MARY FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405125
VISIT DATE: 11/06/2024
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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.

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.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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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: SIETSEMA, MARY FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405125
VISIT DATE: 11/06/2024
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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/.

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 Mary Sietsema, 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 Mary Sietsema.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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