Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310810
Report Date: 03/28/2017
Date Signed: 03/28/2017 05:11:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KEOUGH-SOMMA, GINAFACILITY NUMBER:
304310810
ADMINISTRATOR:KEOUGH-SOMMA, GINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 218-4845
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:14CENSUS: 9DATE:
03/28/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Gina Keough-Somma TIME COMPLETED:
05:30 PM
NARRATIVE
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Annual visit conducted this date. Present was licensee, licensee's assistants Crystal Blair and Thomas Somma as well as nine children in care two of whom were infants.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

The facility was toured inside and out. The following areas were checked: facility clean and in good repair, hazards inaccessible or locked, fire extinguisher, carbon monoxide detector and smoke detector operational, stairs barricaded, fire place screened, bodies of water inaccessible, guns locked, client emergency cards present and pediatric CPR First Aid cards current.

The facility, clean and in good repair, is two story detached. Gate at the bottom of the staircase was in place at the time of the LPA arrival. The smoke detector, carbon monoxide detector and fire extinguisher are within regulation. No one on site has approved pediatric CPR/First Aid cards.
There is a pool in the fenced backyard enclosed by fencing. Pool is within regulation. The fenced backyard is designated for out door by children in care. Licensee said when children in care are playing in the fenced backyard 100% visual supervision is provided.

There are three dogs on the premises. All dogs appeared friendly and approachable. Children paperwork is complete. Licensee denies firearms on the premises.

AB 1368 requiring a small family child care home to have at least one staff on site that has had pediatric CPR/First Aid training was reviewed.
CONTINUED ON PAGE TWO
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2017
Section Cited
102416(c)
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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary
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Licensee said she and her assistants will take the approved pediatric CPR and First Aid classes and the licensee said she would submit to the licensing office a copy of the approved current cards
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resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Licensee's pediatric CPR and First Aid are not approved.
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Type B
04/03/2017
Section Cited
102417(g)
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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child.
The grassy area of the fenced backyard, an area not designated for
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The licensee said this area will be made inaccessible to children in care and she said she will submit to the licensing office a picture of correction.
LPA provided email address.
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use by children in care, is littered with dog feces. The grassy area is accessible to children in care.
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During today's visit the dog feces was picked up from the grass.
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: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 03/28/2017
NARRATIVE
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PAGE TWO
During today’s visit LPA discussed incidental medical services with the licensee. Licensee said there are no incidental medical services being provided at this time.
Licensee to submit updated application listing current resident composition of the home.

In the areas that were evaluated the facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed and cited at the time of the visit.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. If the facility receives a Type 'A' violation the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file.

THE FACILITY REPRESENTATIVE WAS INFORMED THAT THE ‘NOTICE OF SITE VISIT’ MUST BE POSTED FOR 30 CONSECUTIVE DAYS. FAILURE TO POST WILL RESULT IN CIVIL PENALTIES OF $100.00. THE ‘NOTICE OF SITE VISIT’ MUST BE POSTED ON OR ADJACENT TO THE DOOR. FAILURE TO POST TYPE A REPORTS FOR 30 DAYS WILL RESULT IN A CIVIL PENALTY OF $100.00.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2017
LIC809 (FAS) - (06/04)
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