Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310810
Report Date: 12/11/2019
Date Signed: 12/11/2019 12:38:01 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) 235-7946
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:14CENSUS: 6DATE:
12/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gina Keough-Somma, licenseeTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA), Mila Quinto. LPA observed licensee and licensee’s assistant Lysa Shumate caring for 6 children; which included 1 infant and 5 preschool age children. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 3 adults (including the licensee) and 2 minors living in the facility.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of baby gates and latches. The child care area includes the living room, family/kitchen area, one bedroom, one bathroom, and backyard for play area. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger to children were stored inaccessible to children. There is a pool in the backyard with self-latching gate and meets the title 22 regulations. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There were no poisons or other items observed which could pose a danger to children in care. There is a fireplace in the family room screened by a glass cover and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service).

The licensee has a current roster of children in care (obtained copy). Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. At 10:30am, LPA requested the licensee and licensee’s assistant files.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019
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 5
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: 12/11/2019
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

Licensee’s Pediatric CPR/First Aid certification and has an expiration date of April 2019. Licensee states she will renew the CPR/First Aid and will provide copy to Licensing. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis and influenza for licensee were reviewed and missing immunization for measles. Licensee’s assistant does not have proof of immunization against pertussis, and measles, and have a written declaration declining the influenza.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and licensee’s assistant have not completed the required mandated reporter training.

Incidental Medical Services (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

The licensee understands she must be present in the facility and must ensure children in care are supervised at all times and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.



CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 12/11/2019
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 and Health and Safety Code were observed, discussed and cited at the time of the visit. California Code of Regulations, Title 22; Division 12: 102416(c) Personnel Requirements and Health and Safety Code 1597.622(a)(1) Employee and Volunteer Immunization and 1596.8662(b)(1) Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion.

An exit interview conducted with licensee in English. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. 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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 12/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2020
Section Cited

1
2
3
4
5
6
7
102416 Personnel Requirements: (c) The licensee and other personnel as specified shall complete... pediatric cardiopulmonary resuscitation and pediatric first aid...
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observationand review, licensee did not have a current cardiopulmonary resuscitation(CPR). This poses a potential safety risk to children in care.
8
9
10
11
12
13
14
Type B
01/10/2020
Section Cited

1
2
3
4
5
6
7
1597.622 Employee and Volunteer Immunization: (a) (1) Commencing September 1, 2016, a person shall not be employed... at a family day care home if he or she has not been immunized against influenza, pertussis, and measles....receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation and review, the licensee does not have proof of immunization against. The licensee's assistant do not have proof of immunization against measles and pertusis. This poses a potential health risk to children in care.
8
9
10
11
12
13
14
The licensee states she will obtain immunization against measles and licensee's assistant will also provide proof of immunization against measles and pertusis on or before the due date.
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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 12/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2020
Section Cited

1
2
3
4
5
6
7
1596.8662 (b) (1) Mandated Reporter   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provide... or employee of a licensed child day care facility shall complete the mandated reporter training... and shall complete renewal mandated reporter training every two years...
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation and review, the licensee and licensee's assistant have not completed the required mandated reporter training. This poses a pontential safety rish to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5