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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483005218
Report Date: 01/27/2022
Date Signed: 01/27/2022 01:17:10 PM

Document Has Been Signed on 01/27/2022 01:17 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:GARY, MARIE FAMILY CHILD CARE HOMEFACILITY NUMBER:
483005218
ADMINISTRATOR:GARY, MARIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 208-1381
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 10DATE:
01/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Licensee Marie GaryTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Anaylst (LPA) Elpidia Hernandez Torres arrived unannounced to conduct a complaint investigation, through the course of investigation LPA identified the following deficiencies;

LPA arrived at 09:11AM and found Licensee was providing care for 10 children ages two- nine years old without an assistant. Licensee called assistant at 09:37 AM and assistant arrived at 09:48AM. LPA reviewed ratio regulation with licensee.

Licensee was not documenting 15 minute checks, nor had LIC 9227 on file for infant in care. LPA Hernandez Torres provided Safe Sleep regulations and reviewed the documentation requirements with licensee.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Notice of Site Visit shall be posted for 30 days. Appeal Rights were provided. Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 2
Document Has Been Signed on 01/27/2022 01:17 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 01/27/2022 at 11:44 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: GARY, MARIE FAMILY CHILD CARE HOME
FACILITY NUMBER: 483005218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
102416.5(e)

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If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This was not met as evidence by. . .
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Licensee stated I usually have an asistant here but they had an emergency and could not be here. I do have neighbor and my mom lives behind me. I will have them associated and fingerprinted to the facility. Licensee will make sure to have an assistant present at before getting to child number 9. Licensee will submit LIC 9098 with the plan attached.
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based on observation at 09: 28AM, licensee was supervising 4 children aged two, 3 children aged three, 1 child aged four, 1 child age five, and 1 child aged nine for a total of 10 children without an assistant. This poses an immediate health and safety risk to children in care.
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[email protected]
1450 Neotomas Avenue Ste 100 Santa Rosa CA 95405
707-588-5099 Fax
Type B
01/31/2022
Section Cited
CCR102425(j)

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The provider shall supervise infants while they are sleeping and adhere to the following requirements: . . . If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, the provider shall return the infant to their back for sleeping... Documentation shall include the following: a. Date. b. Infant’s name. c.Time of each 15-minute check. This has not been met as evidence by. . .
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Licensee will review childrends records and ensure and infants in care will have the documents required for safe sleep. Licensee will take safe sleep course and submit doucmention to LPA Hernandez Torres on or before 01/31/2022.
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based on interview and record review, Licensee indicated she placed infant on their back initially to sleep. licensee was not conducting required 15 minute checks, nor had LIC 9227 on file there for could not ensure child's sleeping position.
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[email protected]
1450 Neotomas Avenue Ste 100 Santa Rosa CA 95405
707-588-5099 Fax
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:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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