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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010214
Report Date: 11/29/2023
Date Signed: 11/29/2023 08:51:33 AM

Document Has Been Signed on 11/29/2023 08:51 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, 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: 3DATE:
11/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Angeleka Smith-WinstonTIME COMPLETED:
09:00 AM
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Licensing Program Analysts(Glenn Ouye and Robert Maciel) conducted an unannounced case management visit regarding an incident which was occurred on September 6, 2023 and reported to the department on an unusual incident report. LPA's met with licensee Angeleka Smith-Winston. The report indicates that staff S1 gave OTC (over the counter) medication to children C1 and C2 on or about 7pm on September 6, 2023.

Staff S1 was interviewed on the phone on 11/8/23 at 11:27am. S1 admitted to LPA Ouye that she gave each child one gummy OTC medication. S1 said that the licensee was not told that she administered the medication and that the medication was her's which she used for her own children. The parents were not aware that the children would be or were given the OTC medication.

LPA Ouye also conducted a phone interviewed the licensee who said that the children stayed at her home for care until 11pm. She said that C1 and C2's mother picked the children up on 9/6/23 on or about 11pm and immediately called her and told her that her children told her that S1 gave her children the OTC medication. The licensee spoke with the S1 the following day and suspended S1. S1 decided to quit and did not return for employment.

The following violation of the California Code of Regulation, Title 22, Division 12, were cited: see LIC809-D. Appeal Rights were provided.

LPA Ouye informed licensee Angeleka Smith-Winston that this report dated November 29, 2023 documents one Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety and personal rights of the children in care.

Continued on LIC809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SMITH-WINSTON, ANGELEKA FCCH
FACILITY NUMBER: 483010214
VISIT DATE: 11/29/2023
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Also, LPA Ouye informed the licensee to provide a copy of this licensing report dated November 29, 2023, that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Licensee, Angeleka Smith-Winston. 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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2023 08:51 AM - It Cannot Be Edited


Created By: Glenn Ouye On 11/29/2023 at 07:54 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
, 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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2023
Section Cited
CCR
102423(a)(4)

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Each child receiving services from a family child care home shall have certain rights...To be free from corporal or unusual punishment...or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping. This requirement was not met as evidenced by:
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Licensee suspended staff S1 from employement on 9/7/2023 and S1 is no longer employed to clear the deficiency at time of visit.
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n 9/6/23 OTC medication was given to C1 and C2 without written approval from the chiid's authorized representative which poses an immediate health and safety risk to the children. As evidence through an interview with S1 who admits to giving OTC medication to children C1 and C2
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Glenn Ouye
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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