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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 065406666
Report Date: 10/08/2024
Date Signed: 11/26/2024 12:02:46 PM

Document Has Been Signed on 11/26/2024 12:02 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MEDINA, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
065406666
ADMINISTRATOR/
DIRECTOR:		MEDINA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 473-3822
CITY:WILLIAMSSTATE: CAZIP CODE:
95987
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
10/08/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Maria Medina TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 10/8/2024 at 1:45pm, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Laura Chavez. At 1:55pm the home was toured inside and outside. The licensee was supervising 3 children and operating within the licensed capacity and ratio requirements. The facility operates 7 days a week, 24 hours a day. The licensee understands that 24 hour care to one child at one time is not allowed. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the garage and three bedrooms including the master bathroom, and were made inaccessible by locks and doorknob covers. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. The mesh surrounding the trampoline located in the backyard is not secured.

Five children's records were reviewed at 2:56pm. There are currently 2 adults living in the home.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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 7
Document Has Been Signed on 11/26/2024 12:02 PM - It Cannot Be Edited


Created By: Laura Chavez On 10/08/2024 at 04:14 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

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. The mesh surrounding the trampoline is in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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4
Licensee agrees to provide of having removed the trampoline form the outdoor playarea. The plan of correction shall be submitted to CCLD on or before 10/14/2024.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 out of 5 person which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee agrees to provide copies of immunization records for Child #3 and Child #4. The plan of correction shall be submitted to CCLD on or before 10/14/2024.
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:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/26/2024 12:02 PM - It Cannot Be Edited


Created By: Laura Chavez On 10/08/2024 at 04:14 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Child's Records
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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4
 Licensee agrees to provide copies of Parent Notification Additional Children in Care for Child #1, Child #2, and Child #3; The plan of correction shall be submitted to CCLD on or before 11/8/2024.
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:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 12:02 PM - It Cannot Be Edited


Created By: Laura Chavez On 10/08/2024 at 04:14 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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2
3
4
The licensee agrees to submit a completed copy of her roster of children in care to CCLD on or before 11/8/2024.
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:Megan Aviles
LICENSING EVALUATOR NAME:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/26/2024 12:02 PM - It Cannot Be Edited


Created By: Laura Chavez On 10/08/2024 at 04:14 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

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 4 out of 5 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee agrees to provide copies of Family Child Care Home Notification of Parent's Rights (LIC995A)Child #1, Child #2, Child #3, Child #5. The plan of correction shall be submitted to CCLD on or before 11/8/2024.

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:Laura Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


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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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666
VISIT DATE: 10/08/2024
NARRATIVE
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The following deficiencies were cited: 102417(d) - the mesh surrounding the trampoline is in disrepair; 102418(g) - Immunization records not available for Child #3 and Child #4; 102421(a) - Family Child Care Home Notification of Parent's Rights (LIC995A) not available for Child #1, Child #2, Child #3, and Child #5; 102421(c) - Parent Notification Additional Children in Care not available for review for Child #1, Child #2, and Child #3; 102417(g)(8) - Child Care Roster incomplete. (see LIC 809D):

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.

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.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MEDINA, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 065406666
VISIT DATE: 10/08/2024
NARRATIVE
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LPA discussed the safe sleep regulations with licensee Maria Medina 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 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 PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted and the report was reviewed with licensee Maria Medina.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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