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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408331
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:45:02 PM

Document Has Been Signed on 04/18/2024 04:45 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:TSEYANG, KUNGAFACILITY NUMBER:
073408331
ADMINISTRATOR/
DIRECTOR:		TSEYANG, KUNGAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 367-4252
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
04/18/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kunga TseyangTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On 4/18/2024, at 1:00PM Licensing Program Analyst (LPA) B.Crass arrived at the home for an unannounced annual/random inspection. LPA met with licensee Kunga Tseyang. Also present for the inspection were two other adults. One adult did not have a criminal background clearance (See 809-D for deficiency cited during todays inspection). The licensee stated she is an assistant who has been working at the facility for a few months. The second assistant was fingerprint cleared. The licensee was operating over capacity during todays visit, with 7 infants and 4 preschool aged children in care during the inspection. (See 809-D for deficiency cited during todays inspection.) Licensee did not have a current roster (See 809-D for deficiency cited during todays inspection). This family childcare home operates Monday - Friday 7AM-6PM. LPA verified that the licensee's phone number and email address on file are correct.

LPA toured the on-limit areas of the home with the licensee to conduct a health and safety inspection. The home is a single story home. LPA observed that the home is neat and clean with heating and ventilation for the safety and comfort of children in care. The on-limit areas include the family room, sun room, bathroom, and fully fenced in backyard. The children arrive through the right side of the home, and pass through the garage to enter into the family room. The off-limit areas are made inaccessible by closed and/or locked doors, gates, and visual supervision. LPA observed locks on lower cabinets to prevent access by children. The fireplace in the living room is blocked to prevent access by children. LPA observed an ample supply of age-appropriate toys, equipment and activities available for children both indoors and outdoors and observed that they are in good condition. LPA did not observe any bodies of water that would be accessible to children. The licensee stated that there are no firearms on the premises.

(Report continued, See 809-C).

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331
VISIT DATE: 04/18/2024
NARRATIVE
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The home is equipped with fully charged 3A40BC fire extinguisher, a working carbon monoxide detector, working smoke detector, and a working telephone. Licensee has a CPR certificate, however it is not the required infant/pediatric CPR training (See 809-D for deficiency cited during todays visit). Licensees Mandated Reporter Training certificate is current and expires on 2/23/2025. Fire and Earthquake drills have not been conducted every six months (See 809-D for deficiency cited today). LPA observed all of the required forms posted. LPA reviewed children's files, staff files and obtained a copy of the current roster.

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.

LPA reminded the licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. LPA provided the main office number for the Oakland Regional Child Care office (510) 622-2602 for the licensees to call and report injuries or unusual incidents and reviewed the form to follow up in writing within 7 days of the injury/unusual incident. The licensees were encouraged to periodically review regulations, guidelines and Provider Information Notices (PINs) on the website www.ccld.ca.gov.

(Report continued, See 809-C).

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331
VISIT DATE: 04/18/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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 [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/inspection-process.

LPA reminded the licensee that the mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

See 809-D for deficiencies cited during todays visit.

A Type A deficiency was cited during this inspection. Licensee must post the Type A deficiency, provide a copy of this report to all parents of children currently enrolled, and the parents of newly enrolled children in the next 12 months. In addition, form LIC 9224 (Acknowledgment of Receipt of Licensing Reports) must be signed by each parent and placed in each child's file. A copy of the LIC 9224 and AB 633 fact sheet were provided to the Licensee during the inspection.



A civil penalty is being assessed for a citation listed on this report. You will receive a bill in the mail. Payment is due when billed. Payment must be made by a personal, business or cashier check, or a money order made payable to the "California Department of Social Services". Please write the facility number and invoice number on your check and include a copy of your bill with the payment. You will find the invoice number on your bill. DO NOT SEND CASH.

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

Appeal rights provided and discussed.

Exit interview conducted and report was reviewed with the licensee Kunga Tseyang.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by having an adult in the home, Dolma Pasang, not having received a criminal background clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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By end of day on 4/19/2024, the licensee will email LPA a copy of the live scan receipt, showing that the adult went to get fingerprinted. The deficiency will not be cleared until the adult shows as eligible-cleared in Guardian. The adult is not able to return to the home during day care hours until an eligible clearance has been granted.
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having 7 infants and 4 preschoolers in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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By beginning of day on 4/19/2024, the licensee will disenroll 3 infants, in order to be within capacity regulations. Licensee will email LPA a written statement saying she agrees to stay within the capacity regulations going forward. LPA will confirm enrolled children via the updated roster, and will make a visit to confirm the licensee is operating within capacity regulations.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, and record review, the licensee did not comply with the section cited above by not conducting fire and earthquake drills within the last six months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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By 4/25/2024, the licensee will conduct both a fire and an earthquake drill, and will email LPA a copy of the log.
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above by having loose sheets on the mattresses in the cribs, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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By 4/25/2024, the licensee will purchase sheets that fit tightly onto the crib mattresses, and will email LPA a photo showing the sheets fitting tightly onto the mattress.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having items such as toys and blankets in the cribs, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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By 4/25/2024, the licensee will email LPA photos of all infants sleeping in their cribs, revealing nothing inside of the crib while napping.
Type B
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

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 by having infants with pacifier attachments, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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By 4/25/2024, the licensee will email LPA a photo of an infant sleeping with a pacifier, but without the shirt attachment.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by not having 15 minute sleep logs for all infants in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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2
3
4
By 4/25/24, the licensee will email LPA a copy of the 15 minute sleep logs for all infants in care, showing one week of 15 minute sleep checks.
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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by not having her assistant complete the Mandated Reporter Training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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2
3
4
By 4/25/2024, the licensee will have her assistant complete the Mandated Reporter Training, and will email LPA a copy of the certificate.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having completed the correct CPR training for infants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2024
Plan of Correction
1
2
3
4
By 5/16/2024, the licensee will complete the in person training for infant/pediatric CPR/1st aide, and will email LPA a copy of her CPR certificate.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, and record review, the licensee did not comply with the section cited above by having an infant with no file, and no emergency card, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
1
2
3
4
By 4/25/2024, the licensee will obtain a complete file for the infant who did not have one, and will email LPA copies of each form, including the emergency/ID form (LIC 700).
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited


Created By: Brittany Crass On 04/18/2024 at 03:40 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TSEYANG, KUNGA
FACILITY NUMBER: 073408331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, and record review, the licensee did not comply with the section cited above by not having a current roster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
1
2
3
4
By 4/19/2024, the licensee will update her roster, showing the children she has disenrolled, and will email LPA a copy of the updated roster.
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
1
2
3
4
Based on interview, and record review, the licensee did not comply with the section cited above by not having an Individual Infant Sleep Plan for the infant under one years old in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
1
2
3
4
By 4/25/2024, the licensee will have the parents of all infants under one years old complete the Individual Infant Sleep Plan, and will email LPA a copy of the signed form.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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