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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233008242
Report Date: 02/14/2024
Date Signed: 02/14/2024 01:42:23 PM

Document Has Been Signed on 02/14/2024 01:42 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:STULTZ FAMILY CHILD CARE HOMEFACILITY NUMBER:
233008242
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
02/14/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Tonya StultzTIME COMPLETED:
11:58 PM
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 Required Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 2/14/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. 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.

During today’s inspection the home and grounds were toured. The Licensee was supervising 6 children and was operating within the licensed capacity and ratio requirements. One child, child 6 (C6) is a family member of the licensee and is not enrolled in the facility. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30 AM to 5:15 PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the front yard, bedrooms 1 and 2, the laundry room, and the garage, and were made inaccessible by baby gates, door locks, and door latches. The home was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. Licensee stated poisons are locked in the garage whose entrance is locked by a keypad. There is an above-ground pool in the backyard which is blocked off with an iron bar fence. The gate into the pool area in the backyard is locked with a padlock.


Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STULTZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 233008242
VISIT DATE: 02/14/2024
NARRATIVE
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The Licensee conducted an emergency disaster drill within the last six months. The most recent drill was conducted on 1/22/24. The facility roster of the children in care was reviewed and appeared to be complete. LPA reviewed five children's records (C1-C5) at 9:47 AM which revealed C1, C2, and C3 were missing up to date immunization records. LPA reviewed staff and personal records at 9:40 AM which revealed that the licensee did not possess a current mandated reporter training certificate.

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/.



On this date, 02/7/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STULTZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 233008242
VISIT DATE: 02/14/2024
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

Exit interview conducted and report was reviewed with the Licensee, Tonya Stultz. 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. The following violations of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2024 01:42 PM - It Cannot Be Edited


Created By: Robert Maciel On 02/14/2024 at 11:26 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STULTZ FAMILY CHILD CARE HOME
FACILITY NUMBER: 233008242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not possess a current mandated reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Licensee stated she would obtain a current mandated reporter training certificate and send a copy to LPA by email at robert.maciel@dss.ca.gov
Type B
Section Cited
CCR
102418(g)(1)
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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C1, C2, and C3 were missing up to date immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Licensee stated she would obtain up to date immunization records for each child and ensure that the current information is recorded in each child's file and send a copy of the immunization records of C1-C3 to LPA by email at robert.maciel@dss.ca.gov
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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