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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 163901684
Report Date: 11/15/2023
Date Signed: 11/15/2023 07:09:34 PM

Document Has Been Signed on 11/15/2023 07:09 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MOMBERGER, DAWN FAMILY CHILD CAREFACILITY NUMBER:
163901684
ADMINISTRATOR:MOMBERGER, DAWNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 904-6906
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/15/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
06:56 AM
MET WITH:Dawn MombergerTIME COMPLETED:
10:45 AM
NARRATIVE
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On November 15, 2023 Licensing Program Analyst (LPA), Paul Garcia conducted an unannounced Annual Required Inspection and was met by Licensee, Dawn Momberger. Also present was Staff #1 (S1). Days and hours of operation are Monday-Friday from 6:30 AM -5:30 PM. The home has working telephone service and LPA confirmed the phone number is (559) 904-6906.

LPA toured the home inside and outside and a census was taken. There was no facility sketch and licensee could not produce one. Licensee confirmed that the kitchen,dining room, living room, bathroom, play room #1 are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of child safety gates and door locks. LPA observed the following, crafting supplies, books, games, and paper goods on the kitchen table. In the kitchen, LPA observed that the counters were covered with kitchen items, (food products, glassware, and plastic kitchen items). LPA also observed the following in the children’s bathroom, spider webs, spiders, missing light bulbs, and the shower being utilized as a storage area. The outdoor play area in the front yard is not fenced and licensee understands children shall be under direct supervision at all times while children are at play. During today’s visit LPA observed many age-appropriate toys however several toys require removal from the home due to poor quality. There is two medium sized dogs at the home. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets. The swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises.No poisons were observed during the inspection. LPA observed a broken child safety lock to an under sink kitchen cabinet that contained dish washing liquid detergent and disinfecting wipes assessable to children in care.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher/smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home as this is a single level home. Safe toys and play equipment are observed indoors.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Paul Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/15/2023 07:09 PM - It Cannot Be Edited


Created By: Paul Garcia On 11/15/2023 at 08:50 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 when LPA observed a broken child safety lock to an under sink cabinet located in the kitchen that contained a liquid detergent. Also obseved was disinfecting wipes assessable to children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee agrees to replace the child safety lock and provide proof of the correction via photo to LPA by November 22, 2023
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:Duane Matsubara
LICENSING EVALUATOR NAME:Paul Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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Document Has Been Signed on 11/15/2023 07:09 PM - It Cannot Be Edited


Created By: Paul Garcia On 11/15/2023 at 08:50 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation the licensee did not comply with the section cited above when LPA observed the following, crafting supplies, books, games, and paper goods on the kitchen table. In the kitchen, LPA observed that the counters were covered with kitchen items, (food products, glassware, and plastic kitchen items). LPA also observed the following in the children’s bathroom, spider webs, spiders, missing light bulbs, and the shower being utilized as a storage area. These observations pose a potential health and safety risk or personal rights violations to children in care
POC Due Date: 11/22/2023
Plan of Correction
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Licensee agrees to correct the above deficiency’s and submit proof of the correction via photo to LPA by November 22, 2023
Type B
Section Cited
CCR
102425(b)(1)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA observed loose items (Plush blanket, toys other objects) in in one (1) play yard. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Licensee will review safe sleep regulations and write a half page report on play pen requirements for children 0-2 years of age.
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:Duane Matsubara
LICENSING EVALUATOR NAME:Paul Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684
VISIT DATE: 11/15/2023
NARRATIVE
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LPA discussed the safe sleep regulations with licensee 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. During todays visit LPA observed loose items (Plush blanket, toys other objects) in in one (1) play yard.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on March 3, 2022. Licensee’s pediatric CPR/First Aid expires on May 7, 2024. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) are not currently being provided. 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)

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Paul Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MOMBERGER, DAWN FAMILY CHILD CARE
FACILITY NUMBER: 163901684
VISIT DATE: 11/15/2023
NARRATIVE
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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.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D)

Exit interview conducted and report was reviewed with the facility representative Dawn Momberger.

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

Appeal Rights were discussed and issued.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Paul Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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