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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313622314
Report Date: 08/08/2022
Date Signed: 08/08/2022 11:02:33 AM

Document Has Been Signed on 08/08/2022 11:02 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:EAGAN, KACYFACILITY NUMBER:
313622314
ADMINISTRATOR:EAGAN, KACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 401-6212
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kacy EaganTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Lea Habtom and Amanda Blesi met with licensee Kacy Eagan regarding a complaint. During the inspection, LPA L. Habtom created a case management report to address the deficiencies noticed during the inspection.

A census was taken which included 9 children being supervised by licensee, her assistant and oldest child.

During the tour LPAs saw a taco sleeper and a baby walker in the area of the day care home. No children were using the items during the time of the inspection.

LPA L. Habtom was unable to confirm the assistant had fingerprint clearance.

There were Title 22 violations cited during today's visit. See 809-D.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224 form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form during this visit.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/08/2022 11:02 AM - It Cannot Be Edited


Created By: Lea Habtom On 08/08/2022 at 10:25 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EAGAN, KACY
FACILITY NUMBER: 313622314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited
CCR
102417(D)(1)

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102417(D)(1)Operation of a Family Child Care Home: (d)The home shall provide safe toys, play equipment and materials. (1) Fixtures, furniture and equipment that have been banned or recalled by the United States Consumer Protection Safety Commission shall not be used for children in care or accessible to children in care.

This requirement was not met as evidenced by:
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Licensee agreed to move the taco sleeper to the off limits area in the main home.
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A taco sleeper was in the day care area at the time of the inspection. No child was using the sleeper at the time of the inspection.
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Type B
08/08/2022
Section Cited
CCR102417(G)(10)

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102417(G)(10)Operation of a Family Child Care Home: A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Section 1596.846(b) and (c).
(b) A baby walker shall not be kept or used on the premises of a child day care facility.

This requirement was not met as evidenced by:
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Licensee agreed to move the baby walker to the off limits area in the main home.
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A baby walker was noticed at the day care during the inspection. No children were using the baby walker.
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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:Keven Peters
LICENSING EVALUATOR NAME:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2022 11:02 AM - It Cannot Be Edited


Created By: Lea Habtom On 08/08/2022 at 10:34 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EAGAN, KACY
FACILITY NUMBER: 313622314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2022
Section Cited
CCR
102416(D)(1)

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102416(D)(1)Personnel Requirements:
(d) Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations

This requirement was not met as evidenced by:
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Licensee agreed to not have assistant work until fingerprints are cleared.
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Assistant did not have fingerprint clearances.
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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:Keven Peters
LICENSING EVALUATOR NAME:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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