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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364804137
Report Date: 12/03/2024
Date Signed: 12/03/2024 05:41:48 PM

Document Has Been Signed on 12/03/2024 05:41 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:DAVIS FAMILY CHILD CAREFACILITY NUMBER:
364804137
ADMINISTRATOR/
DIRECTOR:		SANDRA DAVISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 421-3617
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 14TOTAL ENROLLED CHILDREN: 23CENSUS: 5DATE:
12/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Sandra DavisTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On the date and time listed, Licensing Program Analysts (LPAs) Eric Ramos and Perla Ordones arrived at the facility to conduct an inspection regarding a separate matter. During the course of inspection, LPAs observed an infant in a baby bouncer in the play room. This is a violation of the Health and Safety Code.

In addition, LPAs observed several accessible poisons/toxins, such as detergents and cleaning products, in the on-limits washer/dryer area and living room area. Licensee stated that children are allowed in the living room area and sometimes watch TV in the living room area. Additionally, LPAs observed children come into the living room area during the visit while poisons/toxins were accessible. This is a violation of Operation of a Family Child Care Home regulations.

While LPAs were conducting record review, LPAs observed that the children's roster is not current. Licensee attempted to locate the most current roster but was unable to provide a current roster during the visit. In addition, LPAs observed that staff records were not complete as one staff member who was present was missing their entire file. Additionally, both the Licensee and the staff member present were missing a valid EMSA approved CPR/1st Aid certificate. This is a violation of Title 22 regulations.

See LIC809-D for cited deficiencies.

LPAs Eric Ramos and Perla Ordones informed Licensee Sandra Davis that this report dated 12/03/2024 document(s) two Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/03/2024 05:41 PM - It Cannot Be Edited


Created By: Eric Ramos On 12/03/2024 at 03:59 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
HSC
1596.846(c)

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(b) A baby walker shall not be kept or used on the premises of a child day care facility.
(c) A "baby walker" means any article described in paragraph (4) of subdivision (a) of Section 1500.86 of Part 1500 of Title 16 of the Code of Federal Regulations.
This regulation is not met as evidenced by:
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Licensee agrees to remove the baby bouncer and agrees to provide proof to Community Care Licensing (CCL) by the Plan Of Correction (POC) due date of 12/4/2024.
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Based on observation, the facility did not comply with the section cited above as LPAs observed an infant in a baby walker in the play room which poses an immediate health and safety risk to persons in care.
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Type A
12/04/2024
Section Cited
CCR102417(g)(4)(A)

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(4) Poisons, detergents, cleaning compounds... which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
(A) Storage areas for poisons... shall be locked.
This regulation is not met as evidenced by:
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Licensee agrees to move the poisons/toxins to an off-limit key locked area and agrees to provide proof to Community Care Licensing (CCL) by the Plan Of Correction (POC) due date of 12/4/2024.
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Based on observation, the facility did not comply with the section cited above as LPAs observed several accessible poisons/toxins, such as detergents and cleaning products, in the on-limits washer/dryer area and living room area which poses an immediate health and safety risk to persons 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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137
VISIT DATE: 12/03/2024
NARRATIVE
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LPAs Eric Ramos and Perla Ordones also informed Licensee Sandra Davis to provide a copy of this licensing report dated 12/03/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted and report was reviewed with licensee Sandra Davis.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Eric Ramos
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/03/2024 05:41 PM - It Cannot Be Edited


Created By: Eric Ramos On 12/03/2024 at 04:40 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
102417(g)(8)

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(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This regulation is not met as evidenced by:
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Licensee agrees to update roster and agrees to provide proof to Community Care Licensing (CCL) by the Plan Of Correction (POC) due date of 12/17/2024.
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Based on observations and record review, LPAs observed that the children's roster is not current which poses a potential health and safety risk to persons in care.
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Type B
12/17/2024
Section Cited
CCR102416.1(d)

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(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This regulation is not met as evidenced by:
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Licensee agrees to create and maintain a personnel record for all employees and agrees to provide proof to Community Care Licensing (CCL) by the Plan Of Correction (POC) due date of 12/17/2024.
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Based on observation and record review, LPAs observed that staff records were not complete as one staff member who was present was missing their entire file which poses a potential health and safety risk to persons 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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 12/03/2024 05:41 PM - It Cannot Be Edited


Created By: Eric Ramos On 12/03/2024 at 04:54 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: DAVIS FAMILY CHILD CARE
FACILITY NUMBER: 364804137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
102416(c)

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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 regulation is not met as evidenced by:
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Licensee and staff present during inspection agrees to enroll in and complete EMSA approved CPR/1st Aid training and agrees to provide proof to Community Care Licensing (CCL) by the Plan Of Correction (POC) due date of 12/17/2024.
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Based on observation and record review, LPAs observed both the Licensee and staff member present were missing a valid EMSA approved CPR/1st Aid certificate which poses a potential health and safety risk to persons 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:Ana Noble
LICENSING EVALUATOR NAME:Eric Ramos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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