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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515407891
Report Date: 02/01/2024
Date Signed: 02/01/2024 09:35:10 AM

Document Has Been Signed on 02/01/2024 09:35 AM - 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:SHIELER, ELLISA FAMILY CHILD CARE HOMEFACILITY NUMBER:
515407891
ADMINISTRATOR:SHIELER, ELLISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 551-3226
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
02/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Ellisa ShielerTIME COMPLETED:
09:45 AM
NARRATIVE
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On 2/1/24 at 9:14 AM Licensing Program Analyst (LPA) Mendez and LPA Sims conducted a Case Management unannounced visit to follow up on uncleared adult providing assistance on 9/22/23 and was observed providing assistance on 10/16/23. It was observed that the assistant was not listed on the Guardian roster

A violation of The California Code of Regulations, Title 22; Division 12 was determined. Type A violation for uncleared adult, which poses an immediate health, safety, or personal rights risk to persons in care. Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 and is to be kept in each child’s file.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 3
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: SHIELER, ELLISA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515407891
VISIT DATE: 02/01/2024
NARRATIVE
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See LIC809D

A copy of the report, appeal rights and a notice of site visit were given.

Exit interview was conducted with Licensee Ellisa Shieler

Notice of site visit must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/01/2024 09:35 AM - It Cannot Be Edited


Created By: Bianca Mendez On 02/01/2024 at 09:17 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SHIELER, ELLISA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515407891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
HSC
10237(d)(1)

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102370 Criminal Records Clearance (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1 )Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee stated that the uncleared assistant does not work at the facility. Licensee will have families complete the LIC 9224 and will be placed in children's files.
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This requirement is not met as evidence by: Based on observation and interview, the licensee was operating with an uncleared adult in the facility, which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Bianca Mendez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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