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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313607928
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:04:53 AM

Document Has Been Signed on 02/06/2025 11:04 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MADSEN, ROBYNFACILITY NUMBER:
313607928
ADMINISTRATOR/
DIRECTOR:		MADSEN, ROBYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 305-4394
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
02/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Robyn MadsenTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 2/6/2025 at approximately 09:50AM Licensing Program Analyst (LPA) Michelle Perez met with Licensee, Robyn Madsen, for an unannounced inspection. During the inspection there was a census of 08 CHILDREN (6 preschool and 2 infants) supervised by two assistants. Licensee was not present when LPA arrived and had a schedule appointment. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Thursday 8:00 AM to 5:30PM and Friday 8:00AM to 5PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Upstairs and garage. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed a fireplace that is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted September 2024. Licensee's has current CPR/First aid, which expires January 2026. Licensee’s Mandated Reporter Training expires January 2026. One assistant present has mandated reporter training updated and one assistant's mandated reporter trianing expired February 2024. Licensee was not present, and no assistant had current CPR. One CPR was expired, and one did not have CPR certifcation. LPA reviewed records of children’s files, and notated that some of the infant files were missing the LIC 9227 (Infant Sleep Plan).

SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MADSEN, ROBYN
FACILITY NUMBER: 313607928
VISIT DATE: 02/06/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. No children on medical services currently. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee is aware and practicing safe sleep regulations. LPA observed the infant sleep logs.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

Deficiencies were cited during today’s inspection on 809-D

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days

SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/06/2025 11:04 AM - It Cannot Be Edited


Created By: Michelle Perez On 02/06/2025 at 10:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADSEN, ROBYN
FACILITY NUMBER: 313607928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA arrived and assistant was away for an appointment.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee will submit to LPA that they are aware of CCR 102417(a) and must be present, not allowing assistant(s) to run the facility, as they are not licensed. Submit to LPA by POC date above.
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 comply with the section cited above in one out of two assistants did not have current mandated reporter training as it expired 02/2024.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Assistant will submit updated mandated reporter training to LPA by POC date above.
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:Mai Lor
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/06/2025 11:04 AM - It Cannot Be Edited


Created By: Michelle Perez On 02/06/2025 at 10:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADSEN, ROBYN
FACILITY NUMBER: 313607928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

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
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Based on record review, the licensee did not comply with the section cited above in two out of two assistants did not have current CPR certification. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee will submit proof of CPR for one of the assistants, that is always present in the facility, by the POC date above. Assistant is scheduled for a class on 02/08/2024. Licensee will work with second assistant to complete CPR, if that assistant will be left alone.
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:Mai Lor
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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