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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009801
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:55:22 PM

Document Has Been Signed on 10/03/2023 12:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MOONEY, ANN FCCHFACILITY NUMBER:
493009801
ADMINISTRATOR:ANN MOONEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 335-5259
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ann MooneyTIME COMPLETED:
01:15 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. LPA met with Licensee, Ann Mooney. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. There are currently four adults living in the home.

During the inspection the home was toured inside and outside. The licensee was supervising 6 children. Review of facility roster confirmed that 5 of the children in care were infants between 16 and 23 months of age. The facility’s operating hours are Monday - Thursday 8:00 AM - 4:00 PM. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the backyard, the classroom, the kitchen, and the bathroom. The off-limits areas of the home are the upstairs bedroom, and the studio. The off-limits areas of the home were made inaccessible by child gates. The home appears to be 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. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated no poisons are stored at the facility and none were observed. Licensee stated there is no pool or hot tub at the facility and none were observed. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home.

Continued on LIC 809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801
VISIT DATE: 10/03/2023
NARRATIVE
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LPA observed no cribs or play yards in the facility. Upon asking the Licensee what sleeping equipment she uses for the infants in care, Licensee stated that she uses individual cots for all children.

The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months, last drill was documented on 10/03/23. 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 10:30 am. Facility and personnel files were reviewed at 10:50 am which revealed that S1 and S2 were missing current Mandated Reporter Certificates. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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

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



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: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801
VISIT DATE: 10/03/2023
NARRATIVE
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Exit interview conducted and report was reviewed with the licensee, Ann Mooney.

The following deficiencies of the California Title 22 Code of Regulations were cited. Please see LIC 809-D. Appeal rights were provided.

LPA Robert Maciel informed licensee Ann Mooney, that this report dated 10/03/23 documents 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Robert Maciel informed the licensee to provide a copy of this licensing report dated 10/03/23 that documents any Type A citation(s) 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 (LIC 9224), or other written statement, must be placed in the child's file for verification.

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 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: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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Document Has Been Signed on 10/03/2023 12:55 PM - It Cannot Be Edited


Created By: Robert Maciel On 10/03/2023 at 12:00 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: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the Licensee was caring for 5 infants at one time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Licensee called a parent of C4 to come pick him up on 10/3/23 at 3:00 pm.
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


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Document Has Been Signed on 10/03/2023 12:55 PM - It Cannot Be Edited


Created By: Robert Maciel On 10/03/2023 at 12:00 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: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

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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Based on observation and interview, the licensee only uses cots for all children in her care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee stated she would request a crib or play yard from the parents of all infants in care and would a request a statement from parents confirming that their children are able to climb out of a crib/play yard once they are able to do so and send picture of either to LPA by email at [email protected]
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 observation and interview, licensee did not record the 15 minute checks for all infants in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee stated she would begin recording the checks on a sleep log provided by the LPA and send a copy of a complete sleep log for each child to LPA by email at [email protected]
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2023 12:55 PM - It Cannot Be Edited


Created By: Robert Maciel On 10/03/2023 at 12:00 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: MOONEY, ANN FCCH
FACILITY NUMBER: 493009801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

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 review and interview, Licensee and S2 did not possess a current Mandated Reporter Training Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee stated both S2 and her would take the Mandated Reporter Training course and email a copy of their certificates to LPA at [email protected]
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


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