<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009938
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:21:08 PM

Document Has Been Signed on 06/01/2022 04:21 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OBIEDO, TERESA FCCHFACILITY NUMBER:
483009938
ADMINISTRATOR:OBIEDO, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 342-7631
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 12DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Teress Obiedo - LicenseeTIME COMPLETED:
04:40 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
A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 06/01/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There is currently one adult living in the home. 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.

During today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising twelve children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 5:00am to 12:00am, Mon–Sun. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are one bedroom, kitchen and garage and were made inaccessible by a child safety gate and door locking mechanism. The children have access to the living/family rooms, two bedrooms, two bathrooms and the backyard. The home was clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The fireplace was securely screened. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. LPA did not observe any poison(s). The Licensee stated there were no firearm(s) or other dangerous weapons stored on site.

LPA reviewed three staff (LS, S1 & S2) records at 1:16pm which contained current AB 1207 Mandated Reporter Training certificate, Criminal Record Statement, and staff required immunization records. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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 5
Document Has Been Signed on 06/01/2022 04:21 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/01/2022 at 03:22 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OBIEDO, TERESA FCCH
FACILITY NUMBER: 483009938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee not furnishing evidence to prove that 15-minute checks were/had been conducted for C7, C8 & C9. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
1
2
3
4
Licensee stated she would document 15 minutes checks for on the Sleep Log for each child under 24 months old and Licensee would submit completed LIC 9098 and two days worth of completed Sleep Log to prove that 15 minutes checks were being conducted by 06/08/22 via mail, email or fax. Email: [email protected] Fax: 707-588-5099
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OBIEDO, TERESA FCCH
FACILITY NUMBER: 483009938
VISIT DATE: 06/01/2022
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
26
27
28
29
30
31
32
 Ten children’s (C1-C10) records were reviewed at 2:05pm which contained Identification and Emergency Information, Consent for Emergency Medical Treatment, Parent Rights, Immunization Records (IR) and IR transcribed CDPH 286.

During today’s inspection, there were three children under 24 months old that were unable to climb out of the play yard, however; there were only two play yards available. LPA issued a Technical Violation for this deficiency. The Licensee did not furnish evidence to proof that 15-minute checks had been conducted for C7, C8 & C9. The facility conducted an emergency disaster drill within the past six months and the last drill was documented on 03/03/22. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee's EMSA approved pediatric CPR expire on 04/2023 and First Aid expire on 06/2023.

The backyard appeared to be free of hazards and was fully fenced. There were no pools or other bodies of water observed in the yard.

The facility is not providing Incidental Medical Services (IMS) to children in care. Incidental Medical Services (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
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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OBIEDO, TERESA FCCH
FACILITY NUMBER: 483009938
VISIT DATE: 06/01/2022
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
26
27
28
29
30
31
32
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/process.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5