394500342-10-26-2023-53-CC-DNGN-CWYUQ9-20231026154645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500342
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:47:14 PM

Document Has Been Signed on 10/26/2023 03:47 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	EVELYN, PATRICIA		FACILITY NUMBER:	394500342
ADMINISTRATOR:	EVELYN, PATRICIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 487-2610
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	LInda Brown		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On October 26, 2023, at 12:40 PM, Licensing Program Analyst (LPA) David Nguyen met with Licensee’s Assistant, Linda Brown for the purpose of an unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPA was granted for entry by Licensee’s Assistant. The Licensee was not present at time of inspection. Licensee's helper was present with Licensee's Assistant at the start of inspection. There were three (3) children present at the start of inspection. Licensee's operating hours are Monday through Friday from 4:00 AM. to 3:00 AM. Meals—breakfast, AM snack, lunch, PM snack, dinner, nighttime/bedtime snack—are provided to daycare children. Bottled water is provided to daycare children for drinking water. LPA reminded Licensee’s Assistant that Licensee has an annual license fees balance. LPA gave the Licensee’s Assistant the PIN number for the Licensee to pay her annual license fees. All adults subject to criminal background review have obtained criminal record clearance. 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. Report continues on LIC-809-C....(Page 2)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EVELYN, PATRICIA	FACILITY NUMBER: 394500342
	VISIT DATE: 10/26/2023

NARRATIVE

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A health and safety inspection was conducted in all areas accessible to children. The detached one-story single-family home has 3 bedrooms, 2 bathrooms, and attached 2-car garage. The off-limits areas in the home include the master bedroom and master bathroom, and bedroom # 2. The off-limits areas remain inaccessible with closed doors and SUPERVISION. The on-limits areas in the home include the living room, the dining area, the kitchen, the laundry room, the bathroom in the hallway, the attached 2-car garage, bedroom # 1, the backyard. LPA observed the required postings and a working phone. 2A10BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives were inaccessible to children in care. LPA observed playroom area with age-appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. Licensee's assistant stated there are no weapons in the home. Outdoor play space is fenced. There are no bodies of water on the premises.

Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted NOT at least once every six months. The last fire drill was conducted on 7/6/2022. Licensee's immunization records are available in the facility file Licensee’s current EMSA pediatric CPR and First Aid certification was verified and expires 11/7/2023, and Child Care Provider Mandated Reporter certification was verified and expires on 10//27/2023. Licensee’s Assistant pediatric CPR and First Aid certification was verified and has no completion date and expiration date. Licensee’s assistant Child Care Provider Mandated Reporter certification was verified and expires on 10/20/2024.

Report continues on 809-C....(Page 3)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EVELYN, PATRICIA	FACILITY NUMBER: 394500342
	VISIT DATE: 10/26/2023

NARRATIVE

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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 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 discussed the requirement to check and log infant napping every 15 minutes, for infants under 24 months. LPA provided Licensee a copy of LIC 9227—Individual Infant Sleeping Plan. LPA discussed the requirement to complete the Individual Infant Sleeping Plan for infants under twelve (12) months of age. LPA observed 15-minute infant napping logs for infants 24 months and under. LPA also observed copies of LIC 9227 Individual Infant Sleeping Plan for infants under 12 months.

LPA discussed the Year-Round/Daily Reminder of Water Safety Requirements and Measures with licensee. LPA provided licensee the PIN 23-17-CCLD, the Year-Round and Daily Reminder of Water Safety Requirements and Measures.

This provider is not currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Report continues on LIC809-C....(Page 4)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EVELYN, PATRICIA	FACILITY NUMBER: 394500342
	VISIT DATE: 10/26/2023

NARRATIVE

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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/inspection-process

Exit interview conducted and report was reviewed with the licensee. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, LPA Nguyen informed licensee’s Assistant, Linda Brown that this report dated October 26th, 2023 documents two (2) Type B citations during today’s inspection.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2023 03:47 PM - It Cannot Be Edited

Created By: David Nguyen On 10/26/2023 at 02:49 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EVELYN, PATRICIA	FACILITY NUMBER: 394500342
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to coduct the fire drill once every six (6) months and log the fire drill on the log upon completion of the fire drill. Licensee also agrees to submit the completed fire drill log to LPA by the due date of Plan of Correction (11/27/2023).

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 in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have her assistant obtain the Pediatric CPR and First Aid and submit the certificate of completion for Pediatric CPR and First Aid to LPA by the due date of Plan of Correction (11/27/2023).

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:

Chayntel Hunter

LICENSING EVALUATOR NAME:

David Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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