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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045407653
Report Date: 09/27/2021
Date Signed: 10/01/2021 04:08:29 PM

Document Has Been Signed on 10/01/2021 04:08 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:DAVIS, MELISSA FAMILY CHILD CARE HOMEFACILITY NUMBER:
045407653
ADMINISTRATOR:DAVIS, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 682-9330
CITY:GRIDLEYSTATE: CAZIP CODE:
95948
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Melissa DaivsTIME COMPLETED:
02:35 PM
NARRATIVE
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On 9/27/2021 at 1:10pm, Licensing Program Analyst (LPA) Laura Chavez conducted a Required -1 year inspection. The facility file was reviewed prior to this visit. A review of the Facility Personnel Report Summary dated 9/13/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. Currently three adults reside in the home. The home and grounds were toured, and the licensee was operating within the licensed capacity. No children were observed in parked cars. The licensee's days and hours of operation are Monday-Friday: 7:30am - 4:30pm. There is a working telephone in the home. The floor & yard plan were verified. The home is clean and orderly, with ventilation for safety and comfort. LPA observed toys, play equipment and materials available for children to be safe. The fire extinguisher, smoke detector and carbon monoxide detector in the home meet the standards required. Detergents, cleaning compounds, medications, and other items which could pose a danger to children are stored and inaccessible to children. Poisons are inaccessible to children by means of a locked box located in garage. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. Five children’s records were reviewed at 1:25pm, and contained emergency identification forms. The licensee understands that any child showing signs of illness shall be separated from other children. The licensee has not renewed her Mandated Reporter Training and CPR and First Aid as required.
Report Continued: See LIC809-C
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: DAVIS, MELISSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 045407653
VISIT DATE: 09/27/2021
NARRATIVE
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The licensee's immunization's are on file. The fenced in side yard of the home serves as the children's outdoor play area. The pool located in the backyard is fenced in as required. The gate is self-closing, self-latching and swings away from the pool. The latching device is no more than 6" from the top. The lid on the spa located in the backyard is locked as required. An alarm and lock have been installed on the sliding glass door leading into the backyard which has been designated as off-limits to children. This report was reviewed and discussed with the Licensee. All licensing reports are public information and must be made available upon request for at least three years. An exit interview was conducted with the licensee, a plan of correction was discussed, and appeal rights were provided.
Notice of Site Visit shall be posted for 30 days from today's visit.

The following Type B violations of the California Code of Regulations, Title 22; Division 12, were cited: See LIC 809-D
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2021 04:08 PM - It Cannot Be Edited


Created By: Laura Chavez On 09/27/2021 at 01:55 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: DAVIS, MELISSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 045407653

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child
day care provider of a licensed child day care facility shall complete the Mandated Reporter Training (MRT) required and shall renew the training every two years following the date on which he or she completed the initial training.
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The licensee agrees to provide proof of renewal of the MRT to CCLD on or before 10/27/2021.
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This requirement was not met as evidenced by; the licensee not renewing the MRT which she initialling completed on 8/7/2019.
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Type B
10/27/2021
Section Cited
CCR102416(c)

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Personnel Requirements: The licensee and other personnel as specified, shall complete training on preventive health practices including pediatric CPR and first aid.

This requirement was not met as evidenced by;
The licensee not renewing her CPR/First Aid which expired on 8/3/2021.
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The licensee agrees to provide proof of completing her CPR/First Aid training to CCLD on or before 10/27/2021.

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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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


LIC809 (FAS) - (06/04)
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