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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053622969
Report Date: 10/15/2021
Date Signed: 10/15/2021 12:40:22 PM

Document Has Been Signed on 10/15/2021 12:40 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:KELLY, SARAHFACILITY NUMBER:
053622969
ADMINISTRATOR:KELLY, SARAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-2295
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
10/15/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Sarah KellyTIME COMPLETED:
12:45 PM
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On 10/15/21 Licensing Program Analyst (LPA) Aruna Sridharan met with licensee Sarah Kelly for unannounced annual inspection. LPA followed infection control protocols. The hours of operation are 7:00am to 5:00pm Monday through Friday.

The family child care home facility is single story family home with three bedrooms, two bathrooms, living room, kitchen and garage. Today's census is 5 children including 1 infant and 4 preschoolers. Off limit areas: three bedrooms, garage and backyard. Licensee acknowledges that children may never enter these off-limit areas. The side yard is fenced where children's outdoor play area is set up. Licensee was notified that prior to use of any off limits area, the department must be notified.

A tour of the home, inside and outside, as shown on the facility sketch was conducted. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. The first aid kit is located in the daycare closet. As per the licensee, there are firearms locked separately. LPA observed cleaning compound's under the kithen sink and cabinet next to bathroom with child safety latch. Medications were stored in cabinet above the sink. Licensee informed that she does not provide overnight care.
Safe toys and play equipment are observed. LPA observed all the required postings, reviewed all staff and childrens records. Licensee and staff had expired mandated reporters and staff did not have proof of immunizations. As it is potential risk to the health and safety of chidren, Type B deficiencies are sited on 809D page.
LPA discussed the Safe Sleep regulations. LPA observed the record of licensee’s immunization on file. LPA reviewed children's roster and fire drill log last conducted on 01/21. This is again a potential risk to the health and safety of children. Type B defiiciency is cited on 809D page. LPA requested a copy of children's roster from the licensee. Licensee had CPR/First aid card that expires on 03/23.

LPA advised the facility to follow all the Covid precautions while providing care for children.
Report continues on 809C page...
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/15/2021 12:40 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/15/2021 at 11:20 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KELLY, SARAH
FACILITY NUMBER: 053622969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

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 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Licensee will complete Mandated Reporter for herself and all staff and send copies to LPA by the POC date.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Licensee will submit proof of immunizations for Staff 1 to LPA by POC 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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


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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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: KELLY, SARAH
FACILITY NUMBER: 053622969
VISIT DATE: 10/15/2021
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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 [email protected]. 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/process.

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.

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 [facility representative] 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.

Title 22 Deficiencies observed in the areas of today's facility evaluation are on 809D page.. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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Document Has Been Signed on 10/15/2021 12:40 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 10/15/2021 at 11:56 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KELLY, SARAH
FACILITY NUMBER: 053622969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Licensee will conduct a fire drill and document and send proof of fire drill to LPA by POC 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:Justin L Denton
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


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