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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233007705
Report Date: 05/09/2025
Date Signed: 05/09/2025 02:18:59 PM

Document Has Been Signed on 05/09/2025 02:18 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:REYNOSO/PALMERIN FAMILY CHILD CARE HOMEFACILITY NUMBER:
233007705
ADMINISTRATOR/
DIRECTOR:		REYNOSO, CLAUDIA & PALMERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 972-1609
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
05/09/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Claudia Reynoso & Osvaldo PalmerinTIME VISIT/
INSPECTION COMPLETED:
02:28 PM
NARRATIVE
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Plan of Correction (POC) visit and met with Licensees, Claudia Reynoso (L1) & Osvaldo Palmerin (L2) to address outstanding deficiencies that were cited on 03/04/2025.

On 3/4/25, the facility received 7 type B citations for not recording 15-minute sleep checks for an infant in care, not possessing a complete LIC9227 Individual Infant Sleeping Plan for a child under the age of one, not possessing complete record of child immunization for children in care, not performing a disaster drill within the last 6 months, allowing an infant to sleep in a playpen with a blanket and pillow, Licensees and assistant not possessing current Mandated Reporter Training Certificates, and Licensees and assistant not possessing complete record of required measles, pertussis, and influenza immunizations.

On 3/6/25, L2 submitted the missing LIC9227 Individual Infant Sleeping Plan, completing the plan of correction. L2 also submitted immunization records for child 1 (C1) and child 3 (C3) and immunization records for L2. On 4/24/25, L2 submitted Mandated Reporter Training Certificates for L1, L2, and assistant (A1), completing the plan of correction. The remaining uncompleted plans of correction are to submit 15 minute sleep logs for child 1 (C1) from 3/5/25 to 3/12/25, submit a copy of the facility disaster drill log, submit a statement attesting to Licensee's understanding of the safe sleep regulations, and to submit a complete immunization record for child 2 (C2), child 4 (C4), L1, and A1.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: REYNOSO/PALMERIN FAMILY CHILD CARE HOME
FACILITY NUMBER: 233007705
VISIT DATE: 05/09/2025
NARRATIVE
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During today's visit, LPA observed 10 children in care. LPA reviewed the children's files which revealed that C2 and C4's immunization record were complete, completing the plan if correction. Licensee showed LPA 15-minute sleep log for C1 from 3/5/25 to 3/12/25. The plan of correction for the sleep log has been met and deficiency cleared. LPA observed the facility disaster drill log which showed the most recent fire drill had been performed as of 4/7/25, completing the plan if correction. L1 showed LPA her immunization record that shows proof of immunization against pertussis. L2 submitted a written statement attesting to their understanding of the safe sleep regulations to LPA, completing the plan of correction. Review of facility roster of children in care revealed that child 5 (C5) and child 6 (C6) were not listed on the roster.

Exit interview conducted and report was reviewed with Licensees, Claudia Reynoso and Osvaldo Palmerin. The following violation(s) of the California Code of Regulations, Title 22 were observed (see LIC809D). Appeal rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 02:18 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/09/2025 at 01:46 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: REYNOSO/PALMERIN FAMILY CHILD CARE HOME
FACILITY NUMBER: 233007705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
HSC
1597.622(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
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Licensee (L1) stated she would obtain complete immunization records for A1 and submit a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, the facility did not possess record of the Assistant's (S3) proof of immunization against measles or pertussis which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/30/2025
Section Cited
CCR102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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Licensee (L1) stated she would update the roster with C5 and C6's information and send LPA a picture of the roster by email to robert.maciel@dss.ca.gov.
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Based on record review, two children present, child 5 (C5) and child 6 (C6), were not listed on the roster of children which poses a potential risk to the health, safety and personal rights of persons in care.
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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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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