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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409126
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:31:52 PM

Document Has Been Signed on 11/22/2021 12:31 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:ALLEN, MELISSAFACILITY NUMBER:
073409126
ADMINISTRATOR:ALLEN, MELISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 509-4014
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
11/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Melissa AllenTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/22/2021, Licensing Program Analysts (LPA's) Melissa Guirit and Diana Campos met with Licensee Melissa Allen for the purpose of conducting a complaint investigation regarding a day care child wandering away from the home. During the course of the investigation LPA's discovered that licensee's fence was in disrepair resulting in the child wandering away and licensee's failure to report the incident to the licensing office.

See LIC809D for the following Type B deficiencies being cited during today's investigation.
Exit interview conducted with licensee and a Notice of site visit was posted.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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 2
Document Has Been Signed on 11/22/2021 12:31 PM - It Cannot Be Edited


Created By: Diana Campos On 11/22/2021 at 11:47 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: ALLEN, MELISSA
FACILITY NUMBER: 073409126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
102417(g)(6)

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The home shall be free from defects or conditions which might endanger a child... Outdoor play areas shall be either fenced or outdoor play shall be supervised by the licensee or caregiver. This requirement was not met as evidenced by:
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Licensee agrees to repair the fence. However licensee has since repaired the fence.
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A day care child wandered away from the home without licensee's knowledge, due to disrepair in the licensee's back yard fence. This poses a potential risk to the health and safety of children in care.
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Type B
11/29/2021
Section Cited
CCR102416.29(b)(2)

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The licensee shall report to the department any of the events...Any child absence means any instance where a child in care is missing. For example any child in care who wanders away from the family child care home...This requirement was not met as evidenced by:
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Licensee shall submit a written LIC624 (Unusual Incident Report) by the POC due date.
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Per licensee she was not aware that she must report this incident to the licensing office. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2