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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622189
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:57:28 PM

Document Has Been Signed on 05/02/2024 03:57 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BILGI, AYSEFACILITY NUMBER:
313622189
ADMINISTRATOR/
DIRECTOR:		BILGI, AYSE & BILGI, AVNIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(401) 612-4677
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Bilgi, AyseTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On May 2, 2024 at 1:00 p.m., Licensing Program Analysts (LPA) Pa Dao Vang met with Licensee, Ayse Bilgi, for an unannounced case management inspection. There was also an assistant in the home. There were 7 children in care during nap time.

Upon arrival, LPA observed 2 infants sleeping with sleep sacks on inside the cribs.

Title 22 Deficiency has been cited on the attached LIC 809-D. LPA Pa Dao Vang informed Licensee, Ayse Bilgi, that this report dated May 2, 2024 documents 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Pa Dao Vang informed the Licensee to provide a copy of this licensing report dated May 2, 2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Appeal Rights given.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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Document Has Been Signed on 05/02/2024 03:57 PM - It Cannot Be Edited


Created By: Dao Vang On 05/02/2024 at 02:10 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BILGI, AYSE
FACILITY NUMBER: 313622189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/03/2024
Section Cited
CCR
102425(f)102425(f)

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102425 Infant Safe Sleep
(f) An infant shall not be swaddled while in care.

This requirement was not met, evidenced by:
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Licensee will submit to LPA Vang, correspondence stating that she will not use sleep sacks/suits through email.Licensee removed the sleep sack immediately. LPA provided a business card to Licensee with contact info.
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Based on observation and interview, there were 2 infants sleeping in the cribs with sleep sack in the napping area, which posed a potential health, safety or personal rights risk to persons in care .Licensee stated she was not aware of it and no one trained her on it.
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Dao Vang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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