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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623829
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:16:55 PM

Document Has Been Signed on 07/23/2024 05:16 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:JOHNSON, ERIQUETTAFACILITY NUMBER:
343623829
ADMINISTRATOR/
DIRECTOR:		JOHNSON, ERIQUETTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 222-9492
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
07/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Eriquetta JohnsonTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 07/23/2024 at 2:45 PM, Licensing Program Analysts (LPAs) Loraine Perez and Matt Gallo met with Licensee, Eriquetta Johnson for the purpose of an unannounced annual/random inspection. During today’s inspection no assistant was present. All individuals subject to criminal background review have obtained a criminal record clearance. Facility hours of operation are Monday- Friday from 7:00 AM to 5:00 PM. Present today is a census of eight children total, one infant and seven preschool aged children. No school age children were present at the time of visit. A family child care home that is licensed as a large must follow the capacity of a small family child care home when no assistant is present.

A health and safety evaluation was conducted in all areas accessible to children. Off-limit areas include: garage, laundry room, living room, dining area, and entire upstairs and both side yards. Licensee acknowledged that children may never enter these off-limit areas. LPAs observed that the facility is clean, safe, sanitary, and in good repair. LPAs observed a functioning smoke detector, carbon monoxide detector, and a full 2A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons and poisons are kept locked. Licensee has placed a gate between the family room and the stairs. The fireplace which is located in the family room is barricaded and not used. There are no bodies of water on the premises.

LPAs reviewed eight children’s files which were observed to be complete. Required postings and the children’s roster were observed. LPAs observed that the last fire drill was conducted 6/12/2024. Licensee’s CPR/First Aid card expires 08/2024. Licensee's Mandated Reporter Training is valid and expires 03/2026. Licensee was reminded to renew both certificates every two years.

PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 6
Document Has Been Signed on 07/23/2024 05:16 PM - It Cannot Be Edited


Created By: Loraine Perez On 07/23/2024 at 04:15 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: JOHNSON, ERIQUETTA
FACILITY NUMBER: 343623829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

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 by providing care to eight children none of which are enrolled and attending elementary school, with no assistant present, which poses an immediate health, and safety risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee stated she will create a wrtiten schdule including the presence of an assistant. Licensee will also record a week of attendance of children and staff present to demonstrate maintaining capacity and ratio.
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:Amanda Blesi
LICENSING EVALUATOR NAME:Loraine Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/23/2024 05:16 PM - It Cannot Be Edited


Created By: Loraine Perez On 07/23/2024 at 04:15 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: JOHNSON, ERIQUETTA
FACILITY NUMBER: 343623829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Amanda Blesi
LICENSING EVALUATOR NAME:Loraine Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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: JOHNSON, ERIQUETTA
FACILITY NUMBER: 343623829
VISIT DATE: 07/23/2024
NARRATIVE
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LPAs verified that the annual fees are current. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the day. Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. Licensee understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. Licensee understands that if she wants to make any changes to OFF-limit areas to an ON-limit area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. Licensee understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to 3 years.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.


Page 2. REPORT CONTINUES ON LIC809C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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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: JOHNSON, ERIQUETTA
FACILITY NUMBER: 343623829
VISIT DATE: 07/23/2024
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Title 22 Deficiency has been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Eriquetta Johnson.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/23/2024 05:16 PM - It Cannot Be Edited


Created By: Loraine Perez On 07/23/2024 at 04:26 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: JOHNSON, ERIQUETTA
FACILITY NUMBER: 343623829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
102425(j)(2)(D)(c)

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:… c. Time of each 15-minute check.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Licensee, the licensee did not comply with the section cited above by stating that she remains in the room with the sleeping infants to observe the infants are not in distress, but she does not document the observations she makes which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee states she will begin to record 15 minute sleep checks and will email a sample of sleep checks to LPA Perez
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:Amanda Blesi
LICENSING EVALUATOR NAME:Loraine Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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