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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010214
Report Date: 11/07/2023
Date Signed: 12/11/2023 04:28:36 PM

Document Has Been Signed on 12/11/2023 04:28 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SMITH-WINSTON, ANGELEKA FCCHFACILITY NUMBER:
483010214
ADMINISTRATOR:SMITH-WINSTON, ANGELEKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 504-5177
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Angeleka Smith-WinstonTIME COMPLETED:
04:50 PM
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During the course of a complaint investigation, Licensing Program Analyst (LPA), Robert Maciel conducted a Case Management visit and met with Licensee, Angeleka Smith-Winston, to deliver two deficiencies that were observed. During the course of the investigation, interviews corroborated that an adult 6 (A6), without a criminal record clearance, transported day care children for the licensee and that the Licensee did not report an unusual incident to the department that occurred on 9/7/23. On 10/03/23 Licensee, Angeleka Smith-Winston, disclosed to LPA Maciel that on 09/07/23 adult 1 gave Melatonin to child 1 and that she had not reported the incident. On 10/19/23, LPA Maciel requested the Licensee send in a written unusual incident report to the Santa Rosa Regional Office.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Angeleka Smith-Winston. The following violation of California Code of Regulations, Title 22, Division 12, was cited during today's visit. Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file. Appeal Rights were provided.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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Document Has Been Signed on 11/07/2023 04:41 PM - It Cannot Be Edited


Created By: Robert Maciel On 11/07/2023 at 03:38 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: SMITH-WINSTON, ANGELEKA FCCH
FACILITY NUMBER: 483010214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2023
Section Cited
CCR
102370(d)(1)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
This requirement is not met as evidenced by:
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Licensee stated she would send adult 6 (A6) to get criminal record clearance and that he would not work for the facility until clearance is obtained.
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Based on interviews, adult 6 (A6) works for the licensee and did not possess a criminal record clearance which poses an immediate 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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/07/2023 04:41 PM - It Cannot Be Edited


Created By: Robert Maciel On 11/07/2023 at 03:38 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: SMITH-WINSTON, ANGELEKA FCCH
FACILITY NUMBER: 483010214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2023
Section Cited
CCR
102416.2(b)(3)(C)

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A report shall be made to the Department…following the occurrence during the operation of a family day care home of any of the following events: … Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement is not met as evidenced by:
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During the course of the visit, Licensee gave the written UIR to LPA Maciel.
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Based on interviews and observation, licensee failed to report an incident to the department which poses 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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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