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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310810
Report Date: 01/31/2024
Date Signed: 01/31/2024 10:44:56 AM

Document Has Been Signed on 01/31/2024 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KEOUGH-SOMMA, GINAFACILITY NUMBER:
304310810
ADMINISTRATOR:KEOUGH-SOMMA, GINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 235-7946
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/31/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gina Keough-Somma - LicenseeTIME COMPLETED:
10:45 AM
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An office meeting was held with licensee Gina Keough-Somma with LPA Carmen Odom and LPM Judy Hanson to discuss the following citations issued on 09/27/2023 during an inspection and to assist the licensee in meeting the requirements of the California Code of Regulations (CCR), Title 22, Division 12.

The following was discussed:

CCR 102421(a) – Type A – Child’s Records: (a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). Based on observation, interview and record review, licensee did not have children’s records for C4 and C5.

CCR 102421(b) – Type A – Child’s Records: (b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). Based on observation, interview, and record review, licensee did not have an emergency information card for C4 and C5.

CCR 102418(g)(1) – Type B – 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. Based on observation, interview, and record review, licensee did not have updated immunization records for children enrolled in the program. LPA provided a resource to obtain records. CA vaccination records website.

CCR 102417(g)(8) – Type B – 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 be limited to: (8) Each family childcare home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. Based on observation, interview, and record review, licensee did not have a roster for children in care. Continue to page 2

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 01/31/2024
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CCR 102417(g)(7) – Type B – 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 be limited to: (7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. Based on observation, interview, and record review, licensee did not have a complete emergency information card for C4 and C5.

CCR 102417(g)(9)(A)1 – Type B - Operation of A Family Child Care Home: (g) The home shall be free from defects or conditions that might endanger a child. Safety precautions shall include but not limited to: (9) Each family childcare home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family childcare home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family childcare home. Based on observation, interview and record review, licensee did not have documentation for drill logs.

CCR 102425(c) – Type B - Infant Safe Sleep: (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. Based on observation, interview, and record review, licensee did not have an LIC9227 available for review.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 01/31/2024
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CCR 102425(c)(2) – Type B - Infant Safe Sleep: (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. (2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. Based on observation, interview, and record review, licensee did not maintain an LIC9227 for infants in care.

CCR 102425(j)(2) – Type B - Infant Safe Sleep: (j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2) The provider shall check and document the following: Based on observation, interview, and record review, licensee did not have sleep logs available for review for infant enrolled.

CCR 102425(j)(2)(D) – Type B - Infant Safe Sleep: (j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2) The provider shall check and document the following: (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date. b. Infant’s name. c. Time of each 15-minute check. Based on observation, interview, and record review, licensee did not have an infant file available for review.

The licensee stated the following:

I do agree that i should have had the 2 children's files completed. The children were pretty new to the childcare about 2 months. I already obtained all the documents for the 2 children that were missing files. I already update the children's roster, the 2 new children were missing on the roster. I have been trying to get blue immunization cards from Public Health but I haven't been able to get the blue form so i made copies of the immunization card. I had the door closed when the infant was napping because it can get loud with the older children. When the infant goes down for a nap I will set up a 15 minute alarm on Alexa app to remind me to document on the napping log. It's been hard conducting a fire drill with young children but I will practice by going outside and if i have to relocate i will go to a neighbors house. I don't have blankets inside the cribs for infants, but i do have a two year old that uses a blanket inside the crib.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEOUGH-SOMMA, GINA
FACILITY NUMBER: 304310810
VISIT DATE: 01/31/2024
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LPM discussed TSP, licensee did not accept TSP at this time.

LPM discussed: Webinars for DSS and Resource & Referral Agency - LPM discussed unannounced visit.

Printed Resources Provided:
-LIC 311D – Forms/Records To Keep in Your Family Child Care Home
-Safe Sleep – Frequently Asked Questions/What Does a Safe Sleep Environment Look Like?/ Infant Safe Sleep – 102425
-LIC125 Entrance Checklist Family Child Care Homes
-LIC627 Consent for Emergency Medical Treatment
-LIC700 Identification and Emergency Information CCC/FCCH
-LIC9227 Individual Infant Sleeping Plan
-NIH PIB No.22-HD-5759 What Does A Safe Sleep Environment Look Like? Flyer
-Child Care Advocate Program Flyer
-Technical Support Program Flyer
-CCL E-Learning Modules flyer

Licensee agreed to complete the following training and provide a training certificate to LPA in two weeks 2/15/2024.

Safe Sleep Academy https://www.safesleepacademy.org/safe-sleep-training/
Additional Resources for licensee and can submit certificates to LPA to file in licensee’s file.
CECO: California SIDS Program Stories, Public Service Announcements (PSAs), and Training Videos/ Health & Safety FAMILY CHILD CARE, HEALTH AND SAFETY, INFANTS AND TODDLERS, LICENSING, PRESCHOOL /Infant/Toddler Learning & Development: Program Guidelines
CECO Website: https://www.caearlychildhoodonline.org/
California SIDS Program: https://www.cdph.ca.gov/Programs/CFH/DMCAH/SIDS/Pages/default.aspx
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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