<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173008469
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:57:32 PM

Document Has Been Signed on 10/09/2024 01:57 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:NOBLE, KEELY FCCHFACILITY NUMBER:
173008469
ADMINISTRATOR/
DIRECTOR:		NOBLE, KEELYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 349-4438
CITY:UPPER LAKESTATE: CAZIP CODE:
95485
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/09/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Keely NobleTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An inspection was made to the facility by Licensing Program Analyst (LPA), Sebastian Phouthavong. LPA met with Licensee, Keely Noble. 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 two adults living in the home.

During the inspection the home was toured inside and outside. The licensee was supervising 8 children and not operating within the licensed capacity and ratio requirements. The Licensee did request a daycare parent to pick up their two children in whch was completed during the time of visit. The facility’s operating hours are Monday - Friday 7:30am - 5:30pm. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the bottom floor of the home and play yard area. The off-limits areas of the home are the upstairs and garage made inaccessible by door locks, plastic doorknob covers and/or child gates. 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 was expired. 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 no poisons stored on the premises and none were observed during today's inspection. 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 05/2024. 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. Three children's records were reviewed at 11:38AM. Facility and personnel files were reviewed and contained required records.


Continued on LIC 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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 3
Document Has Been Signed on 10/09/2024 01:57 PM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 10/09/2024 at 01:08 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: NOBLE, KEELY FCCH
FACILITY NUMBER: 173008469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above and did not provide proof of a current Pediatric CPR & First Aid Certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Licensee stated to have already scheduled an appointment for an in-person Pediatric CPR & First Aid Training and will provide proof of completion to LPA once completed by 11/01/2024.
Type B
Section Cited
CCR
102416.5(b)(3)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (3) More than six and up to eight children, without an additional adult attendant, only if the criteria in
Section 1597.44 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation & Licensee's interview, the licensee did not comply with the section cited above, having 8 children present: one Infant Child and 7 Pre-School Children in which 2 were not at least age 6 and/or enrolled in and attending kindergarten, including transitional kindergarten or elementary school, which posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Licensee was provided the regulation on Capacity Requirements and during the visit, Licensee requested a Daycare Parent to picked up two daycare children in which they were picked up during the time of inspection. Licensee also stated she will submit a statement on her understanding of the Capacity Requirements and the facility's plan to ensure that the requirements are being meet at all times. Licensee will submit it by 11/01/2024.
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: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NOBLE, KEELY FCCH
FACILITY NUMBER: 173008469
VISIT DATE: 10/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 809

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.

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, 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, Keely Noble.

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: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3