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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364805583
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:09:17 PM

Document Has Been Signed on 10/28/2024 04:09 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:CULPEPPER FAMILY CHILD CAREFACILITY NUMBER:
364805583
ADMINISTRATOR/
DIRECTOR:		EVELYN & KATINA C.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 218-0253
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
10/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Katina CulpepperTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 10/28/2024 at 12:15 PM, Licensing Program Analyst (LPA) Tiffanie Diep arrived at the facility to conduct an annual inspection. LPA toured inside and outside of the home, reviewed records, and observed and/or discussed the following:
  • Licensee Katina Culpepper’s parent/assistant (S2) and a non-client adult resident (S3) were also present during the inspection.
  • Normal days and hours of operation are Monday through Friday from 6:30 AM to 6:30 PM.
  • Off-limits areas include: the first bedroom on the left of the hallway, first bedroom on the right of the hallway, and garage.
  • The facility was operating within the licensed capacity and appropriate ratios.
  • Appropriate supervision was provided during the inspection.
  • A working telephone was present with current number on file.
  • An appropriate fire extinguisher was present (2A10BC). A functioning smoke detector and carbon monoxide detector were present and tested by Licensee during the inspection.
  • Fireplace was properly screened by furniture to prevent access by children in care.
  • All hazardous items were stored inaccessible to children.
  • Toxins were locked.
  • There are no weapons present in the home per Licensee. Licensee understands all firearms, weapons, and ammunition must be locked separately and made inaccessible to children in care according to Title 22 Regulations.
  • Facility is a one-story home.
  • Facility sketches, Emergency Disaster Plan (LIC 610A), and Notification of Parents' Rights poster (PUB 394) were posted.
  • Preventive health and safety training was completed on 02/11/2006.

Continues on LIC 809-C
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CULPEPPER FAMILY CHILD CARE
FACILITY NUMBER: 364805583
VISIT DATE: 10/28/2024
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Continued from LIC 809 (Page 2)
  • Pediatric CPR and first aid certification expired on 08/27/2024. LPA discussed the requirement to renew CPR and first aid certification every two years prior to expiration.
  • Mandated Reporter Training certificate expires on 10/20/2025.
  • Licensee confirmed there are no accessible bodies of water on the premises at this time. Licensee understands all bodies of water, including in-ground and above-ground pools, hot tubs, spas, and ponds, must be inaccessible to children in care and be properly covered or fenced according to Title 22 Regulations. The Department must be notified prior to installation of these and similar bodies of water.
  • Clean, safe, and age-appropriate toys were present in the living room area.
  • A current roster of children was on file.
  • Documentation of fire and disaster drills was on file; last drill was conducted on 10/01/2024.
  • Children’s records were complete.
  • Staff records were not complete. LPA did not observe required immunizations for S2. LPA reminded Licensee to maintain documentation of the required immunizations for all employees and volunteers.
  • Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting e-mail at UnusualIncidentReportsDO09@dss.ca.gov.
  • Licensee can submit transfer forms to associate new individuals or to disassociate someone from their facility via e-mail to Associations_Disassociations862@dss.ca.gov.
  • The Duty Officer is available to answer questions Monday through Friday from 8:00 AM to 5:00 PM at (951) 782-4200.
  • Resident and/or staff records reviewed during today’s inspection indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

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 five 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.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CULPEPPER FAMILY CHILD CARE
FACILITY NUMBER: 364805583
VISIT DATE: 10/28/2024
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Continued from LIC 809-C (Page 3)

LPA 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.

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) or (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/.

To improve the quality and value of the new inspection process, a survey may be sent to the e-mail address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE Tool, please send e-mail inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process. Licensee was informed of the MyChildCarePlan.org site, 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.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CULPEPPER FAMILY CHILD CARE
FACILITY NUMBER: 364805583
VISIT DATE: 10/28/2024
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Continued from LIC 809-C (Page 4)

Based on LPA’s observation, interview conducted, and records reviewed, deficiencies are being cited on the attached LIC 809-D. LPA Tiffanie Diep informed the licensee, Katina Culpepper, that this report dated 10/28/2024 documents two Type B citations as there were potential risks to the health and safety of children in care.

An exit interview was conducted and report was reviewed with the licensee, Katina Culpepper. During the exit interview, Licensee confirmed that there are no registered sex offenders (RSO) living in the facility and LPA completed the RSO profile in the Field Automation System. A notice of site visit was given to Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 04:09 PM - It Cannot Be Edited


Created By: Tiffanie Diep On 10/28/2024 at 03:17 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: CULPEPPER FAMILY CHILD CARE
FACILITY NUMBER: 364805583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

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 observation, interview conducted, and records reviewed, the licensee did not comply with the section cited above as licensee did not ensure they renewed their EMSA pediatric CPR and first aid certification by the expiration date which poses a potential safety risk to children in care.
POC Due Date: 11/28/2024
Plan of Correction
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LPA reminded Licensee to renew CPR and first aid certification every two years prior to expiration. Licensee agreed to provide proof of enrollment and/or completed certificate to LPA by 11/28/2024.
Deficiency Dismissed
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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 influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview conducted, and records reviewed, the licensee did not comply with the section cited above as licensee did not ensure required immunizations were maintained for all personnel which poses a potential health risk to children in care.
POC Due Date: 11/28/2024
Plan of Correction
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LPA discussed the requirement to maintain documentation of the required immunizations for all employees and volunteers. Licensee agreed to provide proof of required immunizations for S2 to LPA by 11/28/2024.
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:Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


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