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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624842
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:35:23 PM

Document Has Been Signed on 03/21/2024 03:35 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:MOTHERSHED MANAFOV, TIYANNAFACILITY NUMBER:
343624842
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
03/21/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ruth IndikTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gagandeep Singh met with licensee’s helper, Ruth Indik, for an annual inspection. The purpose of the inspection was explained. Per helper, the licensee was attending a training on this day. During inspection, there are two children in care with the helper. Licensee is operating within the capacity of this date.

LPA inspected the day care areas. Day Care Areas: Living room, Dining area, Kitchen, Hallway, One bedroom in hallway, Bathroom in hallway. Off limit areas: Master Bedroom, Second bedroom and Garage. During inspection, the helper requested the LPA to inspect the backyard, so that, it can be used for the day care. There is no pool, spa or any other body of water in the house. During inspection, LPA observed the house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. There is a variety of age appropriate toys in the house. LPAs observed licensee has cribs available for the infants. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Cabinets in kitchen and bathroom have child protective locks installed. All unused electrical outlets have child protective covers installed.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee has record of training of preventive health and CPR card valid until February 2025. LPA requested the fire drill log from the helper. The helper was unable to locate the log and was not aware when was last drill conducted. LPA also reviewed the present children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has mandated reporter training completion certificate valid until January 17, 2026. During inspection, LPA did not observe the helper's CPR certification. LPA informed the helper that in the absence of licensee, the individual supervising children must have EMSA approved CPR training. See next page for continuation
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MOTHERSHED MANAFOV, TIYANNA
FACILITY NUMBER: 343624842
VISIT DATE: 03/21/2024
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Continuation from previous page ...............

LPA informed the helper 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.

LPA discussed the safe sleep regulations and the Child Care Licensing Safe Sleep webpage at


https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed L1 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.

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/.

LPA informed about 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. 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.

See next page for deficiencies cited today. Copy of this report was reviewed and provided to the helper. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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Document Has Been Signed on 03/21/2024 03:35 PM - It Cannot Be Edited


Created By: Gagandeep Singh On 03/21/2024 at 02:37 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: MOTHERSHED MANAFOV, TIYANNA
FACILITY NUMBER: 343624842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above LPA did not observe a fire drill log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee will have an updated fire drill log in place. LPA provided a copy of blank log to the helper and informed the helper that drill must be conducted at least every six months.

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:Natalie Dunaway
LICENSING EVALUATOR NAME:Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 03:35 PM - It Cannot Be Edited


Created By: Gagandeep Singh On 03/21/2024 at 02:37 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: MOTHERSHED MANAFOV, TIYANNA
FACILITY NUMBER: 343624842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA did not observe the record of helper's Pediatric CPR training certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Per helper, helper will obtain the Pediatric CPR training. LPA informed the helper that the training must be EMSA approved.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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