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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623207
Report Date: 11/03/2021
Date Signed: 11/03/2021 10:10:36 AM

Document Has Been Signed on 11/03/2021 10:10 AM - 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:NOLAND, NICOLETTEFACILITY NUMBER:
343623207
ADMINISTRATOR:NOLAND, NICOLETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 292-8000
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/03/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Assistant Shelby TurleyTIME COMPLETED:
10:30 AM
NARRATIVE
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LPA Blesi and Owens arrived at the home to conduct a follow up inspection for the complaint that was substantiated on 9/27/21 for licensee not being present in the home. Upon arrival there were two assistants present supervising 7 children. Licensee was not present upon arrival and arrived later during the visit. LPA's were informed licensee was not present because she was home sick due to her daughter had a fever.

Licensee has failed to meet her plan of correction to be present in her home and living in the home. Civil Penalties are assessed in the amount of $100 per day and will continue until the deficiency is corrected.

See LIC 809-D and LIC421FC for deficiency.
Exit interview with licensee
Notice of Site Visit provided.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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 11/03/2021 10:10 AM - It Cannot Be Edited


Created By: Amanda Blesi On 11/03/2021 at 09:41 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: NOLAND, NICOLETTE
FACILITY NUMBER: 343623207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/04/2021
Section Cited
CCR
102417(a)

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The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
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LPA will make a return visit to verify correction.
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This requirement was not met as evidenced by: licensee is not present in the home 80% of the time and is not currently living in the home. Licensee has failed to correct the deficiency therefore civil penalties are assessed in the amount of $700 and will be assessed $100 per day unitl the deficency is corrected.
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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:Keven Peters
LICENSING EVALUATOR NAME:Amanda Blesi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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