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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416146
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:08:12 AM

Document Has Been Signed on 07/13/2022 11:08 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:COLEMAN, TAWNFACILITY NUMBER:
434416146
ADMINISTRATOR:TAWN COLEMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 420-1984
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 17CENSUS: 12DATE:
07/13/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Tawn ColemanTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz conducted an unannounced Case Management- Legal/Non-compliance inspection. LPA met with Licensee, Tawn Coleman, and explained the reason for inspection. The purpose of this inspection is to follow-up compliance on staffing ratio and capacity including caregiver background check as discussed on the informal meeting that Licensee attended on 12/29/2021.

LPA observed that there were 12 children (1 infant, 5 preschool and 6 school age) children. Two of the children in ratio were Licensee's own children and one was Licensee's grandson, . Facility was within ratio and capacity during today's inspection. LPA also observed Licensee's father, whom Licensee stated was assisting her with the care of children until her staff assistant arrives at noon. Also present in the home were Licensee's adult child, Licensee's room mate and 12-year old daughter. All adults living in the home have Criminal Background/Child Abuse Index clearances.

LPA obtained a copy of the facility roster and reviewed the children's files.

As a result of this inspection, a deficiency was issued.
Exit interview conducted and report was reviewed with Licensee, Tawn Coleman.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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 07/13/2022 11:08 AM - It Cannot Be Edited


Created By: Janette Cruz On 07/13/2022 at 10:18 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COLEMAN, TAWN
FACILITY NUMBER: 434416146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
HSC
102416.1(d)

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102416.1 Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
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Licensee will submit to LPA by POC due date complete personnel records as required but not limited to: LIC508Criminal Record Statement, LIC9052 Employee Rights, Proof of Immunization (measles, pertussis, flu), Tuberculosis clearance, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse for adult assistant providing care to children in her daycare.
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Based on interviews and record reviews, licensee did not comply with the section cited above. Licensees' adult assistant did not have personnel records requirements readily available for LPA to review which pose a potential health, 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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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