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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408856
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:36:25 PM

Document Has Been Signed on 01/12/2023 01:36 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:EPPS, TRACYFACILITY NUMBER:
073408856
ADMINISTRATOR:EPPS, TRACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(773) 719-1275
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tracy EppsTIME COMPLETED:
01:37 PM
NARRATIVE
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On 1/12/23 at 12:15 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced case management inspection. LPA met with licensee Tracy Epps and present for the inspection were licensee 1 infant, 2 preschoolers).

During the a complaint investigation it was determined that 3 children in care were diagnosed with RSV and was not reported to CCLD Oakland Regional Office. This is a Type B violation for Reporting Requirements.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Tracy Epps.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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 01/12/2023 01:36 PM - It Cannot Be Edited


Created By: Michelle Sutton On 01/12/2023 at 12:30 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: EPPS, TRACY
FACILITY NUMBER: 073408856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
102416.1(c)(3)

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102416.2 Reporting Requirements (c) In addition to the events specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C), the licensee shall report the following events to the Department: (3) A communicable disease outbreak when determined by the local health authority. The requirement is met by
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By POC date licensee will submit an LIC624B to LPA.
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Based on interviews and record reviews, there was 3 children diagnosed with RSV and was not reported to CCLD. This is an potential risk to Health and Safety or Personal Rights risk to persons in care.
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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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