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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008959
Report Date: 04/13/2022
Date Signed: 04/13/2022 02:48:03 PM

Document Has Been Signed on 04/13/2022 02:48 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:LANCASTER, TASHENA FCCHFACILITY NUMBER:
483008959
ADMINISTRATOR:LANCASTER, TASHENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 731-0257
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Tashena LancasterTIME COMPLETED:
03:00 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 04/13/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adult(s) living in the home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During today’s inspection the home and grounds were toured. The Licensee (LS) was supervising five children and was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30AM to 5:30PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire second floor, kitchen and garage, and were made inaccessible by children’s safety gates. The home was clean and orderly and was at a comfortable indoor temperature. The fireplace was screened by multiple storage bins. The staircase was in the living room was barricaded with a child safety gate. There were safe toys and equipment available for children. There is a working telephone in the home. During today's inspection, the Licensee did not furnish a current EMSA approved Pediatric CPR/First Aid certification. 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. LPA did not observe any poison(s) at the facility.

LPA reviewed four children’s (C1-C4) records at 1:05pm which contained identification and emergency information (LIC 700), Consent for Emergency Medical Treatment, Immunization Records (IR), Parents’ Rights, and LIC 282, however; IR were not transcribed onto the blue CDPH 286. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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: LANCASTER, TASHENA FCCH
FACILITY NUMBER: 483008959
VISIT DATE: 04/13/2022
NARRATIVE
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The Licensee did not furnish her current AB 1207 Mandated Reporter Training certificate. Licensee stated there were no infants enrolled into care and LPA did not see any play yard(s). The facility conducted an emergency drill within the past six months and the last drill was conducted on 01/14/22. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee stated there were no firearms and/or other dangerous weapons in the home. The backyard appeared to be free of hazards and was fully fenced. There were no pools or other bodies of water observed in the yard.

The facility is not providing Incidental Medical Services (IMS) to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm
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.

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. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed. See LIC 809-D for deficiencies. Appeal Rights were provided.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/13/2022 02:48 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 04/13/2022 at 01:43 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: LANCASTER, TASHENA FCCH
FACILITY NUMBER: 483008959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

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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Based on record reviewed which revealed that the Licensee's AB 1207 Mandated Reporter Training certificate was expired. 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: 05/28/2022
Plan of Correction
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Licensee stated she would complete the online AB 1207 Mandated Reporter Training module at, mandatedreporterca.com and she would submit a copy of her current certificate to the Department by 05/28/22 via mail, email or fax. 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 the Licensee not furnishing a current EMSA approved Pediatric CPR/First Aid certification. 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: 05/05/2022
Plan of Correction
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The Licensee stated she would register in an EMSA approved Pediatric CPR/First Aid Aid training and she would submit a copy of her current certification to the Department by 05/05/22 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: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/13/2022 02:48 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 04/13/2022 at 01:43 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: LANCASTER, TASHENA FCCH
FACILITY NUMBER: 483008959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on four children's (C1-C4) records reviewed at 1:05am which revealed C1-C4's Immunization Records were not transcribed onto the blue CDPH 286. 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: 04/20/2022
Plan of Correction
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Licensee stated she would transcribed C1-C4's Immunization Records (IR) onto the blue CDPH 286 and Licensee would submit evidence of the transcribed forms to the Department by 04/20/22 via mail, 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: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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