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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053614375
Report Date: 10/26/2023
Date Signed: 10/27/2023 11:27:20 AM

Document Has Been Signed on 10/27/2023 11:27 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STALCUP, MERLITAFACILITY NUMBER:
053614375
ADMINISTRATOR:MERLITA STALCUPFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 785-2657
CITY:COPPEROPOLISSTATE: CAZIP CODE:
95228
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 3DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stalcup, MerlitaTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/26/23 Licensing Program Analyst (LPA) Corina Beckby, conducted an unannounced annual inspection and met with Licensee, Merlita Stalcup. LIC (126), Entrance Checklist for Family Child Care Homes, was provided and reviewed with Licensee. Present in the facility was Licensee and assistant supervising 3 children including 1 infant. Facility hours of operation are Monday – Friday from 6:00 am – 6:00 pm. LPA verified that annual fees are current.

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.



A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPA observed the posting of the facility license and Notification of Parent Rights. Off-limit rooms are: all bedrooms, master bathroom, laundry room, garage, yard area on left side of home. Off-limits areas will remain inaccessible to children by closed doors, gates, and/or supervision. The licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa.

Cleaning agents and detergents are made inaccessible to children. Poison, toxic and hazardous times are made inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 3A40BC fire extinguisher. Sharp utensils are inaccessible to children. Licensee understands that she must ensure the safety locks are not broken. The backyard is fenced and has sufficient toys. The fireplace in the home has a fixed gate, making it inaccessible to children. Licensee states there are no weapons in the home.

Report continued on 809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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 8
Document Has Been Signed on 10/27/2023 11:27 AM - It Cannot Be Edited


Created By: Corina Beckby On 10/26/2023 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

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 which Licensee could not produce emergency disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have emergency disaster plan completed by due date when LPA returns for a visit
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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 which Licensee could not produce updated fire drill log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will conduct a fire drill within the next month and have a written log available by due date when LPA returns for a visit
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2023 11:27 AM - It Cannot Be Edited


Created By: Corina Beckby On 10/26/2023 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 2 counts out of 7 children's files did not have immunization records and/or updated immunization records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have immunizations for all children enrolled and have them ready for LPA to review during next visit
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

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 7 chldren's files did not have signed parents rights forms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have signed forms for all children enrolled and have them ready for LPA to review during next visit
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/27/2023 11:27 AM - It Cannot Be Edited


Created By: Corina Beckby On 10/26/2023 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 7 children's files did not have completed LIC700 forms completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have LIC700 forms for all children enrolled and have them ready for LPA to review during next visit
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 4 out of 7 children's files reviewed did not have consent for medical treatment forms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have Consent for Medical treatment forms for all children enrolled and have them ready for LPA to review during next visit
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/27/2023 11:27 AM - It Cannot Be Edited


Created By: Corina Beckby On 10/26/2023 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 7 children's files were missing Parent Right forms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have Parents Rights forms for all children enrolled and have them ready for LPA to review during next visit

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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 10/27/2023 11:27 AM - It Cannot Be Edited


Created By: Corina Beckby On 10/26/2023 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 4 out of 7 children's files did not have signed Liability Insurance form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will have Liabilty forms for all children enrolled and have them ready for LPA to review during next visit
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375
VISIT DATE: 10/26/2023
NARRATIVE
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LPA observed a current roster and could not confirm disaster drills are conducted at least once every six months. LPA reviewed 7 children’s files. Preventative health and current pediatric CPR and first aid training was verified for Licensee, and CPR expires 07/30/25. Mandated Reporter Training certificate expires: 08/26/25. Licensee understands the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com.

Licensee currently has no children enrolled that require IMS. Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department. 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 has 1 infant currently enrolled. Licensee is not maintaining sleep logs for all infants in care (under 24 months) and does not have any infants under 12 months. LPA discussed the safe sleep regulations with Licensee and provided 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 provided LIC9227 and example of safe sleep log.

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. LPA encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

Report continued on 809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STALCUP, MERLITA
FACILITY NUMBER: 053614375
VISIT DATE: 10/26/2023
NARRATIVE
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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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. 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/inspection-process.

During the exit interview, the Licensee, Merlita Stalcup, confirmed there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

In the areas that were evaluated, 6 Type B citations were issued that are a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for the deficiency.

An Exit interview was conducted, and the report was reviewed with Licensee, Merlita Stalcup. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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