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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173001005
Report Date: 02/05/2025
Date Signed: 02/05/2025 01:49:04 PM

Document Has Been Signed on 02/05/2025 01:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BLEVINS, JULIE FAMILY DAY CARE HOMEFACILITY NUMBER:
173001005
ADMINISTRATOR/
DIRECTOR:		BLEVINS, JULIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 530-9422
CITY:LAKEPORTSTATE: CAZIP CODE:
95453
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
02/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Julie BlevinsTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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An inspection was made to the facility by Licensing Program Analyst (LPA), Sebastian Phouthavong. LPA met with Licensee, Julie Blevins. 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. There are currently 2 adults living in the home.

During the inspection the home was toured inside and outside. The licensee and assistant were supervising 13 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are Monday - Friday 7:45am - 5:15pm. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the childcare room, living room, one bedroom, kitchen, one bathroom and the backyard. The off-limits areas of the home are the storage room and one bedroom; they were made inaccessible by locks on the doors. The home appears to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire on 02/2026. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. Licensee stated there are not firearms and/or other dangerous weapons in the home and none were observed during this inspection. Licensee stated there are poisons stored on the premises and is locked by key lock. The regulation that poisons are to be locked using a key or combination lock was reviewed. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months; last drill was documented on 01/2025. The home's yard is fully fenced. There were no pools or other bodies of water observed and Licensee confirmed that no bodies of water is on the premise.


(Continued on LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 02/05/2025 01:49 PM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 02/05/2025 at 01:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BLEVINS, JULIE FAMILY DAY CARE HOME
FACILITY NUMBER: 173001005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, two children files were missing proof of Immunization Records and CDPH 286: California School Immunization Records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Licensee stated she will provide the two children’s missing proof of Immunization Records and CDPH 286: California School Immunization Records to the department by 02/26/2025.
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:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BLEVINS, JULIE FAMILY DAY CARE HOME
FACILITY NUMBER: 173001005
VISIT DATE: 02/05/2025
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(Continued from LIC 809)

Four children's records were reviewed at 12:40PM. 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, Julie Blevins, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

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

Exit interview conducted and report was reviewed with the Licensee, Julie Blevins.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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