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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842136
Report Date: 08/30/2024
Date Signed: 08/30/2024 10:47:27 AM

Document Has Been Signed on 08/30/2024 10:47 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KELLEY FAMILLY CHILD CAREFACILITY NUMBER:
334842136
ADMINISTRATOR/
DIRECTOR:		MONICA KELLEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 657-9491
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Makayla McNutt, House ResidentTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
NARRATIVE
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On Thursday, August 30, 2024 at approximately 08:00 AM, Licensing Program Analyst (LPA) Jesse Gardner and Licensing Program Manager (LPM) Deborah Mullen conducted an unannounced Case Management inspection to follow-up on a file review that was conducted by LPA on 08/28/2024. LPA found that the Licensee's LIC279 (Application) submitted to the Department on 03/11/2021 reflected two residents, Resident 1 (R1), and Resident 2 (R2). During the tour of the facility on 08/29/2024, LPA did not find R1, and R2 present. LPA found no day care children present in the facility on today's date.

Upon visit to the facility on 08/29/2024, LPA found several adult residents and interviews revealed that they moved into the facility in 2/2023. Resident's were, Resident 3 (R3), Resident 4 (R4), Resident 5 (R5), Resident 6 (R6), Resident 7 (R7), Resident 8 (R8) , and Resident 9 (R9) were not reported by the Licensee to the Department. LPA found that this violated Title 22.

During a check in Guardian, LPA found that R8 did not have a cleared background, and interview with Licensee revealed that R7 also lives in the facility without a background clearance. Licensee was under the impression that R7 was not 18 years of age. Licensee and R7's parent (R9) explained that there was no fingerprint attempt to obtain a background investigation. Thus, two immediate ($1000) civil penalties were issued.

An exit interview was conducted where a copy of this report was provided along with copies of the LIC809D, LIC421BG, and Appeal Rights. A Notice of Site visit was provided and must remain posted for 30 days. This report shall be public record for three years.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 08/30/2024 10:47 AM - It Cannot Be Edited


Created By: Jesse Gardner On 08/30/2024 at 09:52 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KELLEY FAMILLY CHILD CARE
FACILITY NUMBER: 334842136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2024
Section Cited
CCR
102370(a)

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Criminal Record Clearance:
(a) Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. The Licensee did not ensure that adults living in the home had the background clearance required. This is an immediate health and safety risk to children in care.
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Licensee stated that they will obtain a background clearance for R7, and R8, and provide to the Department by POC date.
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Based on record review, and interview, the Licensee did not adhere to the cited regulation. This requirement was not met as evidenced by:
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Type B
09/06/2024
Section Cited
CCR102416.2(a)(2)

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Reporting Requirements
(a) The licensee shall report the following information the Department ... during normal working hours (8am to 5pm).
(2) Any change in household ..including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday. This requirement was not being met as evidenced by:
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Licensee stated that they will provide an updated LIC279 (application) to show all of the adults living in the home by POC date.
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Based on record review and interview, LPA found that the Licensee did not submit an updated LIC279 when adults moved into the home on/or about 2/2023. This is a potential health and safety risk to children in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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