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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423669
Report Date: 09/22/2021
Date Signed: 09/22/2021 09:49:54 AM

Document Has Been Signed on 09/22/2021 09:49 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:COOPER, ELIZABETHFACILITY NUMBER:
013423669
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elizabeth CooperTIME COMPLETED:
10:15 AM
NARRATIVE
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On 09/22/2021, Licensing Program Analyst (LPA) Brittany Newton conducted an announced visit for the purpose of following up on a Unusual Incident report received in our office on 07/29/2021. This facility is a new location, Elizabeth was previously licensed under (#013423552). The incident happened at the last location. This new facility has not been licensed yet. LPA was met by Elizabeth Cooper. Present for the inspection was 0 children.

The incident report received on 07/29/2021 was regarding a child in care inappropriately touching another child in care during nap time. The Investigations Bureau conducted a investigation regarding the incident. Based on the incident and information gathered, a Type A deficiency is being cited on the attached page and must be corrected by the due date.

Upon receipt of this report, facility shall provide copies of this licensing report to parents/guardians of all children in care at the facility by the end of business day and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

Additionally, a Non-Compliance Conference (NCC) has been scheduled for 09/30/21.

Exit interview conducted, appeal rights provided, and a copy of this report was left with Elizabeth Cooper.
Notice of site visit provided and facility reminded it must remain posted along with this report for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Newton
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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Document Has Been Signed on 09/22/2021 09:49 AM - It Cannot Be Edited


Created By: Brittany Newton On 09/20/2021 at 11:18 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: COOPER, ELIZABETH
FACILITY NUMBER: 013423669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
102417(a)

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Operation of a Family Child Care Home. 102417(a). The licensee shall be present in the home and shall ensure that children in care are supervised at all times.
This requirement was not met as evidenced by:
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Facility agrees to watch training videos on personal rights and supervision on the CCLD training webpage (https://childcarevideos.org) and submit a letter explaining what they learned from the videos to LPA Newton by 09/23/2021.
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Based on interviews conducted and documentation reviewed, a day care child inappropriately touched another day care child during nap time which poses an immediate health, safety, and personal rights risk to children 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Newton
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021


LIC809 (FAS) - (06/04)
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