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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093605882
Report Date: 02/20/2024
Date Signed: 02/20/2024 11:09:37 AM

Document Has Been Signed on 02/20/2024 11:09 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KERSEY, CINDYFACILITY NUMBER:
093605882
ADMINISTRATOR:KERSEY, CINDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 337-9482
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
02/20/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cindy KerseyTIME COMPLETED:
11:30 AM
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Licensing Program Analyst Erwina Pascual-Golamco and Fabian Schwartz (LPA) conducted an unannounced 3 year inspection and met with Licensee, Cindy Kersey. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed 10 children in care with licensee and assistant. Facility hours of operation are Tuesdays and Thursdays 9am – 12 nn. LPA observed that the annual facility 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.

Off-limit areas include: garage, upstairs, and north side of yard. Licensee acknowledged that children may never enter these off-limit areas. The fireplace and stairs are fenced or barricaded. Licensee acknowledges that where children less than five years old are in care, stairs shall be fenced or barricaded. LPA conducted a health and safety inspection in the areas accessible to children and observed that the facility is in good repair and free of hazards with heating and ventilation for safety and comfort. The facility has equipment and age-appropriate materials for children. LPA observed the required documents were posted where visible to parents. LPA observed that there were no hazardous items—such as cleaning compounds, medications, or sharp objects that are accessible to children. The 2A-10-BC fire extinguisher appeared to be in working condition and is accessible. LPA observed the smoke and carbon monoxide detectors are functioning. Licensee stated there are no weapons or firearms on the premises. The backyard is fenced, and licensee acknowledged that in areas that are not fenced, 100% supervision is required. LPA did not observe bodies of water on the premises. Continued on LIC809-C...

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KERSEY, CINDY
FACILITY NUMBER: 093605882
VISIT DATE: 02/20/2024
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LPA observed a current children's roster and fire drill log which was last conducted in 09/23. LPA reviewed sample of children’s files and assistance provided regarding required documentation. LPA observed the CPR/First Aid certificate, however, it was not pediatric and EMSA certified. Mandated Reporter Training (MRT) certificate was valid until 04/25. Licensee was reminded both CPR/First Aid and MRT Child Care portion must be completed every two years.

Licensee is aware of and practicing safe sleep regulations. As an additional resource, LPA discussed the safe sleep regulations with licensee and the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep. 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 https://mychildcareplan.org/; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. LPA reminded licensee about the quarterly updates provided by the Childcare Advocates Program. To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
Continued on LIC809-C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KERSEY, CINDY
FACILITY NUMBER: 093605882
VISIT DATE: 02/20/2024
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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.

Based on the inspection and record review, Title 22 Deficiency has been issued on the attached LIC 809-D page. Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 02/16/24. Appeal Rights and A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview was conducted and report was reviewed with the licensee, Cindy Kersey.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2024 11:09 AM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 02/20/2024 at 10:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KERSEY, CINDY
FACILITY NUMBER: 093605882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA observed Licensee's CPR/FA certificate, but was not Pediatric and EMSA certified, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
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Licensee stated she will enroll in Pediatric CPR/FA and EMSA certified training and will email LPA the certificate by 4PM on POC due date. If licensee needs more time, she will email LPA to extend POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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