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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408850
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:32:09 PM

Document Has Been Signed on 03/30/2022 03:32 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CANNADA, NICOLEFACILITY NUMBER:
073408850
ADMINISTRATOR:CANNADA, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 325-5993
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
03/30/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Nicole CannadaTIME COMPLETED:
03:35 PM
NARRATIVE
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On 3/30/22 at 2:40 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced case management to verify the deficiency cited during the complaint inspection on 10/21/21. LPA met with licensee Nicole Cannada and present for the inspection were licensee, licensee's spouse, 1 infant, 7 preschool and 1 school-age.

Letter of Deficiency Citation Cleared was given to licensee for Type A on 10/21/21.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Nicole Cannada.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 03/30/2022 03:32 PM - It Cannot Be Edited


Created By: Michelle Sutton On 03/30/2022 at 03:04 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CANNADA, NICOLE
FACILITY NUMBER: 073408850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2022
Section Cited
CCR
102416.2(b)

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102416.2 Reporting Requirements (b) The licensee shall report to the Department any of the events [...] that occur during the operation of the family child care home. This requirement is not met as evidence by;
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Licensee will submit an Incident Report (LIC624). Licensee will send a written plan and statement understanding the reporting requirements and how she will ensure compliance with this regulation.
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Based on interviews and record reviews, licensee confirmed not reporting sexual abuse by assistant/son Zachary Cobb of children to CCLD. This poses a potential 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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