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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010038
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:49:13 PM

Document Has Been Signed on 05/09/2023 05:49 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:EL, SHELDON FCCHFACILITY NUMBER:
493010038
ADMINISTRATOR:EL, SHELDONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 708-8676
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Assistant, Yvonne PenaTIME COMPLETED:
06:00 PM
NARRATIVE
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Assistant, Yvonne Pena (S1). 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. S1 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 the inspection the home was toured inside and outside. Two assistants were supervising 8 children, 2 infants and 6 preschool age children and operating within the licensed capacity and ratio requirements. Assistants S1 and S2 stated that Licensee is not present daily. S1 stated that the Licensee has not been present in the home for two weeks and is not currently caring for or interacting with the children. S1 stated that the Licensee pops in to say hi to the children approximately every couple of weeks. S1 stated that she is currently living in the home as a roommate with the Licensee. The facility’s operating hours are Monday - Friday 7:30am - 6:00pm. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home is the entire upstairs and the garage. The upstairs was made inaccessible with a safety gate at the bottom of the stairs. The door to the garage was not locked, and accessible to children. S1 stated that she did not have the key to lock the garage door. LPA observed the shelves in the garage to contain lawn food fertilizer and Sta flo liquid starch. There is a neighboring studio attached to the property which has its own physical address and is not accessible from inside of the child care home. The home was observed 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. S1's pediatric CPR and First Aid certifications were reviewed and expire 5/2024. S1 stated that she does not have poisons on the premises and none were observed during today’s inspection.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 7
Document Has Been Signed on 05/09/2023 05:49 PM - It Cannot Be Edited


Created By: Amy Strother On 05/09/2023 at 04:01 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: EL, SHELDON FCCH
FACILITY NUMBER: 493010038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the garage was accessible to children in care and contained lawn food and liquid starch which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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S1 will reach out to the Licensee and obtain a key to lock the garage. S1 stated that if she is unable to obtain a key to lock the garage she will ensure that the door lock is replaced or a latch is added to make the garage inaccessible.
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Assistants S1 and S2 stated that Licensee is not present daily. S1 stated that the Licensee has not been present in the home for two weeks and is not currently caring for or interacting with the children. S1 stated that the Licensee pops in to say hi to the children approximately every couple of weeks, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Licensee (L1) will review regulation 102417(a), and submit a signed a copy of the regulation, acknowledging that she understands the regulation. L1 will submit a statement outlining how she will meet the regulation.
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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/09/2023 05:49 PM - It Cannot Be Edited


Created By: Amy Strother On 05/09/2023 at 04:01 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: EL, SHELDON FCCH
FACILITY NUMBER: 493010038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

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 interview and record review, the licensee did not comply with the section cited above in one out of two staff files reviewed. S2 did not have a current Mandated Reporter certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Licensee will ensure S2 completes the Mandated Reported Training, submitted updated certificate to LPA by 05/30/23. [email protected]
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 children's files. C2 - C4 did not have form LIC282 on file and Licensee did not have proof of current liability insurance on file for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Licensee will obtain signatures on form LIC282 from C2 - C4's authorized representatives or submit current proof of liability insurance to the Department by 05/30/23. [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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/09/2023 05:49 PM - It Cannot Be Edited


Created By: Amy Strother On 05/09/2023 at 04:01 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: EL, SHELDON FCCH
FACILITY NUMBER: 493010038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 1 infants (C5) files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Licensee will have C5's authorized representative fill out form LIC9227, placing it in C5's file. Licensee will submit a statement outling the requirement of which children in care need form LIC9227 by 05/30/22. [email protected]
Type B
Section Cited
HSC
1596.8595(d)(2)
Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing document that the licensee has received during the prior 12-month period that pertains to a conference conducted by a local licensing agency management representative with the licensee in which issues of noncompliance are discussed AND of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of 5 children's files reviewed (C1 and C5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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S1 stated that she will inform the Licensee (L1) to ensure that parents of C1 and C5 receive copies of the licensing report dated 08/04/22 and will sign and date the LIC9224 form. L1 will scan and email signed copies of the completed LIC9224 forms to LPA by 05/30/23. [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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


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: EL, SHELDON FCCH
FACILITY NUMBER: 493010038
VISIT DATE: 05/09/2023
NARRATIVE
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The facility family room has a gas fireplace which is enclosed and covered with a book shelf. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. S1 has conducted an emergency drill within the past six months, last drill was documented on 04/28/23. S1 stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The children use the backyard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed. Personnel files for S1 and S2 were reviewed, S2's file did not contain a current Mandated Reporter Training certificate. S2 stated that she has not updated her certificate and it expired on 6/2022. Five children's files (C1-C5) were reviewed, LPA noted that 3 out of 5 children's files (C2, C3 and C4) did not contain form LIC282 Affidavit Regarding Liability Insurance and a current Liability Insurance policy was not available during today's inspection. One infant under 12 months (C5) was present during today's inspection. LPA reviewed C5's file, form LIC9227 was not on file. Two of five children's files reviewed (C1 and C5) did not contain form LIC9224 documenting acknowledgement of receipt of licensing report citing a Type A deficiency dated 08/04/22.

LPA discussed the safe sleep regulations with S1 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 S1 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

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 facility representative, Yvonne Pena.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: EL, SHELDON FCCH
FACILITY NUMBER: 493010038
VISIT DATE: 05/09/2023
NARRATIVE
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The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. 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: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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