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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623779
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:28:51 AM

Document Has Been Signed on 09/27/2021 11:28 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:SUNDAY,GREGORY JR.FACILITY NUMBER:
343623779
ADMINISTRATOR:SUNDAY, GREGORY JRFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 904-2089
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
09/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Gregory SundayTIME COMPLETED:
11:45 AM
NARRATIVE
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On September 27, 2021 at 9:15 AM, Licensing Program Analysts Tanya Washington and Christopher Bello met with Licensee's girlfriend Aireonna Dunham for a case management inspection. Upon arrival, Aireonna was providing care and supervision to Child #1. Approximately at 9:40 AM, Licensee arrived to the facility with two more children.

Upon request of children's records, Licensee was unable to provide complete records. Some children only had Child Action attendance forms and some children were either missing information or did not have a file at all. Licensee stated that he currently has twelve children enrolled and none of them had a complete file. Child #1 had an incomplete record and children which Licensee arrived to the facility did not have records at all. During review of other files LPAs observed incomplete or missing records.

LPAs also requested verification of Aireonna's current CPR/ First Aid verification and other required documents which Licensee was unable to provide during the inspection.

Two type B citations are cited on the following LIC809D. Appeal rights provided and a notice of site visit posted.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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 2
Document Has Been Signed on 09/27/2021 11:28 AM - It Cannot Be Edited


Created By: Tanya Washington On 09/27/2021 at 11:04 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: SUNDAY,GREGORY JR.
FACILITY NUMBER: 343623779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
102421(1)(b)

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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:
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Licensee was provided blank licensing forms and explained that each child must have a complete record prior to enrollment.
LPA will return to review records on October 27th or later.
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During today's inspection one child had an incomplete file and two children did not have files at all.
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Type B
10/27/2021
Section Cited
CCR102416(c)

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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.
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Licensee stated that Aireonna has a current certification however he has to look for it. All blank forms required for an adult assistant were provided along with a list of other required documents.
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This requirement is not met as evidenced: Upon arrival Licensee's girlfriend was providing supervision to Child #1 alone, Licensee could not provide proof of her file or current CPR and First Aid certification.
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Licensee will ensure to complete her file by 10/27/2021.

LPA will return to correct the citation.
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:Roxana Saravia
LICENSING EVALUATOR NAME:Tanya Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2