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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622676
Report Date: 07/28/2021
Date Signed: 07/28/2021 01:45:37 PM

Document Has Been Signed on 07/28/2021 01:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS, TRACEYFACILITY NUMBER:
343622676
ADMINISTRATOR:DAVIS, TRACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 942-9089
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Tracey DavisTIME COMPLETED:
02:00 PM
NARRATIVE
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On Wednesday, 07/28/21, at 12:00pm, Licensing Program Analyst (LPA) Jan Hoshida conducted an unannounced random annual inspection and met with Licensee Tracey Davis. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. LPA observed there were four day care children present in the facility during this inspection with Licensee and Licensee's Assistants. The off-limit areas include the garage, laundry room, and entire upstairs. Licensee acknowledged that children may never enter these off-limit areas. Licensee stated there are no new residents in the home since licensure. All adult residents have criminal record clearances. The hours of operation are Monday through Friday from 7:00am to 11:00pm.

LPA observed current CPR/First Aid certificates which expire on 8/2023. LPA discussed recent changes in licensing requirements, including the posting of licensing inspection notices and reports and Parent Notification Requirements. LPA reviewed some children’s files. LPA observed fire drills were conducted at least once every six months and documented.

LPA provided Licensee with Safe Sleep PIN 20-24-CCP, Infant Individual Sleeping Plan (LIC 9227) for children under 12 months, and reviewed sleep logs for the child under two years of age. LPA discussed current COVID-19 child care guidelines with Licensee.


LPA observed that there were no hazardous items accessible to children. LPA observed fireplace which was screened. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe. The backyard is fenced and gated. There are no bodies of water observed. Licensee stated there are no weapons in the home.

REPORT CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: DAVIS, TRACEY
FACILITY NUMBER: 343622676
VISIT DATE: 07/28/2021
NARRATIVE
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This facility does not provide Incidental Medical Services- IMS. 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.

LPA discussed the new Mandated Reporter Training (AB1207) with Licensee. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: HTTP://WWW.MANDATEDREPORTERCA.COM/. LPA observed current Mandated Reporter Training in file for Licensee and was taken on 9/25/2020.

LPA did not observe current Mandated Reporter Training for Licensee's Assistants. LPA also did not observe immunizations for pertussis and measles for Licensee's Assistant/husband.

LPA checked facilities fees and confirmed that it is up to date.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the Licensee can obtain updated licensing information, new regulations and access forms. LPA advised Licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws CHILDCAREADVOCATESPROGRAM@DSS.CA.GOV

In the areas that were evaluated, deficiencies were observed at the time of the visit and cited on LIC 809-D. An exit interview was conducted and report was reviewed with Licensee who stated they understand today’s inspection. Notice of Site Visit was posted and Licensee understands it must remain posted for 30 days.
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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Document Has Been Signed on 07/28/2021 01:45 PM - It Cannot Be Edited


Created By: Jan Hoshida On 07/28/2021 at 01:02 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS, TRACEY
FACILITY NUMBER: 343622676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who. . . is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided. . . shall complete renewal mandated reporter training every two years following the date on
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Licensee stated they will provide proof of Mandated Reporter Training of Licensee's Assistants to LPA by POC date of August 30, 2021.
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which he or she completed the initial mandated reporter training.

This requirement was not met by: LPA did not observe current Mandated Reporter Training for Licensee's Assistants.
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Type B
08/30/2021
Section Cited
HSC1597.622(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an
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Licensee stated they shall submit proof of immunization for pertussis and measles for Licensee's Assistant/husband and shall maintain documentation within Assistant's files.
Proof of correction shall be sent to LPA by POC date of August 30, 2021.
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influenza vaccination between August 1 and December 1 of each year.

This requirement was not met by: LPA did not observe immunizations for pertussis and measles for Licensee's Assistant/husband.
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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:Maria Mayorga
LICENSING EVALUATOR NAME:Jan Hoshida
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


LIC809 (FAS) - (06/04)
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