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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485408079
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:46:53 PM

Document Has Been Signed on 08/30/2024 01:46 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:VALENZUELA, MIREYA FAMILY CHILD CARE HOMEFACILITY NUMBER:
485408079
ADMINISTRATOR/
DIRECTOR:		VALENZUELA, MIREYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 770-5671
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
08/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Mireya Valenzuela - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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An Annual/Random inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 08/30/2024 indicates that not that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. During the visit, adult (A1) was present and according to the Licensee’s statement, A1 moved into the home in June 2024, however; A1 had not obtained a criminal record clearance. According to Department records A1 had not obtained an approved criminal record clearance and as such, an immediate $500 civil penalty is assessed because Licensee did not ensure A1 obtained a criminal record clearance prior to residing in the home. Furthermore, Licensee did not notify the department of A1 moving into the home by submitting an updated Application (LIC 279).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. According to the Licensee, the facility was registered with Solano Family and Children’s Services, Food Program.


During today’s inspection the home and grounds were toured. The Licensee (LS) and one staff (S1) were supervising ten 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 7:00AM to 5:30PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079
VISIT DATE: 08/30/2024
NARRATIVE
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The off-limits areas of the home are the entire second floor and kitchen were made indirectly inaccessible by the converted garage’s door that act as a barrier. 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. Licensee’s pediatric CPR/First Aid certification did not meet the Department’s requirement(s). The staircase near the front entrance was indirectly barricaded by the converted garage door. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. According to the Licensee, she did not store any firearm(s) or other dangerous weapon(s) on the premise. LPA did not observe any poison(s) on the premise.

LPA reviewed six children’s (C1-C6) records at 9:04am which revealed C1 was missing Immunization Record (IR), IR was incomplete & transferred on incorrect Public Health form, missing LIC 627 & LIC 955A & LIC 9150. C2 was missing LIC 627 and IR was not transcribed onto CDPH 286, C3 was missing LIC 627, C5 was missing LIC 627 & IR, and IR was not transcribed onto CDPH 286, and C6 was missing LIC 627 and CDPH 286. Licensee did not furnish record for S1, and Licensee did not furnish evidence of completion for AB 1207 Mandated Reporter Training for staff. Licensee did not furnish evidence of negative Tuberculosis (TB) clearance for S1 & A1, and S1 was missing required staff immunization record. Department records also revealed there was an outstanding balance, and the facility fee was not current. During the visit, there were two children (C1-C2) under 24 months old present, and Licensee stated C1 & C2 were unable to climb out of a crib or play yard, C1-C2 napped on a cot in the living room, and Licensee did not have a crib or play yard for C1-C2 to take a nap. Furthermore, Licensee did not furnish evidence to prove 15-minute checks was/were being conducted while C1-C2 took a nap. The Licensee stated she did not have a disaster drill log. The Licensee did not furnish a facility roster of the children in care.


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. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 12
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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079
VISIT DATE: 08/30/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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, Mireya Valenzuela. 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. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on Licensee statement confirming A1 had not obtained a criminal record clearance and resided in the home since June 2024, and $500 civil penalty was assessed. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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During the visit, Licensee sent A1 to a local livescan vendor to get fingerprinted. Licensee said she intends to submit the completed LIC 9163 to the Department by 08/31/24 via email or fax. Email: [email protected] & Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on Licensee's statement confirming C1-C2 slept on a cot, however; C1-C2 could not climb out of a crib or play yard. 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: 09/03/2024
Plan of Correction
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Licensee stated she would ensure C1-C2 had a valid play yard available for each infant to take a nap. Licensee intends to submit evidence of correction to the Department by 09/03/24. Email: [email protected] & Fax: 707-588-5099
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
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Based on Licensee not furnishing evidence to prove 15 minute checks was/were conducted for C1-C2. 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: 09/13/2024
Plan of Correction
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Licensee agreed to complete and document at least nine days worth of 15 minute checks on infant sleep log for C1-C2, and Licensee intends to submit evidence of compliance to the Department by 09/13/24 via mail, email or fax. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on Licensee not furnishing evidence of current completion of AB 1207 Mandated Reporter Training for herself & S1. 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: 09/13/2024
Plan of Correction
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Licensee stated she & S1 would completed the online training module at mandatedreporterca.com and Licensee intends to submit current and valid Mandated Reporter Training certificates for all staff by 09/13/24. Email: [email protected] & Fax: 707-588-5099
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
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Based on LPA's observation which revealed Licensee's pediatric CPR/First Aid ceritification did not meet department requirements. 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: 09/13/2024
Plan of Correction
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Licensee said she would enroll in an EMSA approved pediatric CPR/First Aid training, Licensee would complete the training and submit a current & valid pediatric CPR/First Aid certification to the Department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on Licensee not having a record available and/or furnishing a record for S1 after LPA requested. 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: 09/13/2024
Plan of Correction
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3
4
Licensee stated she would produce a record for S1 and the record would contain all required licensing forms including LIC 9052 and LIC 9108. Licensee said she intends to submit evidence of S1's complete record to the department by 09/13/24.
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on Licensee's statement confirming A1 moved in the home in June 2024 but Licensee did not submit an updated LIC 279. 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: 09/13/2024
Plan of Correction
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2
3
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Licensee stated she would complete and submit an updated LIC 279 reflecting A1 reside in the home. Licensee said she intends to submit completed LIC 279 to the department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on Licensee not furnishing required staff Immunization Record (IR) for S1. 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: 09/13/2024
Plan of Correction
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2
3
4
Licensee stated she would ensure S1 obtain evidence of immunity against Measles, Pertussis and Influenza. Licensee intends to submit evidence of S1's Immunization Record to the Department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on six children's (C1-C6) records reviewed at 9:04am which revealed C5 was missing evidence of immunization. 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: 09/13/2024
Plan of Correction
1
2
3
4
Licensee stated she would request Immunization Record (IR) from C5's guardian, and Licensee intends to submit evidence of C5's IR to the Department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 11:10 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on six children's (C1-C6) records reviewed at 9:04am which revealed C1-C3 & C5-C6's records were incomplete. 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: 09/13/2024
Plan of Correction
1
2
3
4
Licensee stated she would provide and obtain the required licensing forms form C1-C3 & C5-C6's guardians, and Licensee intends to submit evidence of completed records to the Department by 09/13/24.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee not furnishing a facility roster of the children in care. 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: 09/13/2024
Plan of Correction
1
2
3
4
LPA provide Licensee with a blank LIC 9040, and Licensee said she would complete the roster and submit a copy of the completed facility roster to the Department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 12:28 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on Licensee notit furnishing evidence of negative TB for A1 & S1. 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: 09/13/2024
Plan of Correction
1
2
3
4
Licensee stated she would ensure A1 & S1 obtained evidence of negative TB clearance, and Licensee intends to submit evidence of A1 & S1's negative clearance to the department by 09/13/24. Email: [email protected] & Fax: 707-588-5099
Type B
Section Cited
CCR
102417(g)(9)(A)(1)
The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee's statement confirming she did not conduct and/or document a disaster drill. 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: 09/13/2024
Plan of Correction
1
2
3
4
Licensee agreed to conduct an emergency disaster drill before 09/13/24, and Licensee shall document the drill, and Licensee is required to submit evidence (log) to prove a drill was conducted. Email: [email protected] & Fax: 707-588-5099
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 01:46 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 12:40 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: VALENZUELA, MIREYA FAMILY CHILD CARE HOME
FACILITY NUMBER: 485408079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102384(a)(b)(e)
The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.”

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on department records confirming the facility's annual fee was outstanding. 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: 09/13/2024
Plan of Correction
1
2
3
4
Licensee understood that failure to pay fee would result in forfeiture of license. Licensee said she obtained her fee statement and Licensee intends to pay her fee in full, and Licensee is required to submit evidence or fee payment confirmation receipt to the Department by 09/13/24.
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 12 of 12