<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700322
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:31:24 PM

Document Has Been Signed on 01/29/2024 02:31 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:FARIA FAMILY CHILD CAREFACILITY NUMBER:
367700322
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
01/29/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Brittany Faria, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On January 29, 2024, Licensing Program Analyst (LPA) Calloway met with Licensee, who granted access. LPA and Licensee toured the home inside and outside for an Annual Random inspection. Residing in the home are the Licensee, spouse, and two minor children. The home is licensed for six to eight children. LPA observed five (5) napping day care children with licensee during inspection. Adult visitor inside home, not fingerprint cleared.
Physical Plant: This is a single story 3-bedroom, 2-bathroom home with kitchen, dining room, living room, and garage. Childcare is provided: in Living room (upon entry). Children’s Bathroom: is in hallway on the left (observed with hazards). Unused outlets (not covered). LPA recommended covering. Blinds (vertical). Age-appropriate toys, furniture, and books (observed). Napping equipment (mats, playpen). The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen sink- no safety latch), medicines (inside refrigerator).
Kitchen: (Sliding door/not locked) hazardous items that can pose a danger to children (sharp knives kitchen cabinet- safety latch) Fire/earthquake drills (not current). Roster (not current). The required fire extinguisher (2A10BC) (full/green). Smoke detectors (operable) and carbon monoxide detectors (missing). Fireplace is screened. Home has central AC and heat.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322
VISIT DATE: 01/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Required postings were not present on the wall. LPA recommended moving parent wall near the front door for better viewing. No landline phone, but cell phone.
Off limit areas: Garage (key lock), Bedrooms: #1, #2, #3 (safety knobs), Bathrooms: #2, Back yard (see declaration).
Outside: The backyard is completely fenced. Pets: two dogs (vaccinated). Per Licensee, the small dog interacts with the day care children and larger dog does not. Swing/slide set (not anchored), other age-appropriate toys, bikes, and play equipment. No pool/spa or body of water on the premises. AC unit (roof).
Others: Per Licensee, there are no weapons or firearms on the premises. LPA did not observe any in the home. Required mandated reporter training (not current), CPR/First Aid (Exp:2/2024), and immunizations (current). First Aid kit (observed). LPA viewed staff and children’s files and reviewed all infants in care did not have LIC 9227 form in their files. LPA conducted a staff interview with the licensee. Transportation is not provided. Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed. State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.
The following was discussed with the Licensee:
Maintain capacity and transparency per posted parent rights, Roster requirements (keep updated information always), Documentation for disaster drills (fire and earthquake). Mandatory forms, signed, for the children’s files and provider’s files, updated Safe Sleep regulations. The role and responsibilities of being a mandated reporter were reviewed. Licensee reminded that supervision is always required to children in care. If food is brought in, it is properly labeled. Licensee will check food expiration dates periodically.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322
VISIT DATE: 01/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was advised on how to access forms and regulations for Family Child Care online at www.ccld.ca.gov. Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care and temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. If closed for the day, (no kids), or absent notify Licensing. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified. Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban).
Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (printed out after every visit) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee shall provide a copy any Type A deficiency 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 the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the child's file for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.
Licensee is advised to visit: www.shotsforschool.org for Immunization information.
--Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640
-
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322
VISIT DATE: 01/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
-Family Child Care Providers (Disaster Planning information): https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.Incidental Medical Services (IMS) policy was discussed. 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 prior to providing the IMS. 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.
Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.

Reminder: The On Duty Worker is available for questions at: (661) 202-3318 (Monday-Friday 8am-5pm) and for reporting Unusual Incident Reports (within 24 hours). Written Unusual Incident Reports are sent (using (LIC 624B form) to the following email address: unusualincidentreport@dss.ca.gov within seven (7) days after reporting the incident via telephone.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322
VISIT DATE: 01/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Per Title 22 Regulation, Division 12, Chapter 1, there are deficiencies cited during this inspection. See 809D pages attached to this report.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit, Appeal Rights were provided to Brittany Faria, Licensee. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in $100 civil penalty.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 01/29/2024 02:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/29/2024 at 01:54 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in having a working carbon monoxide detector inside the home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
1
2
3
4
Licensee must provide proof of working carbon monoxide detector to Licensing by POC date of 1/30/24.
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having chemical sprays and shampoos accessible to day care children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
1
2
3
4
Licensee must remove chemicals and show proof to Licensing by POC date of 1/30/24.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 01/29/2024 02:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/29/2024 at 01:54 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in Licensee had a baby rocker inside the day care area during inspection and placed C1 inside which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
1
2
3
4
Licensee will remove the baby rocker from home and provide written proof to Licensing by POC date of 1/30/24.
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in there was an uncleared adult inside the home when LPA arrived which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
1
2
3
4
Licensee shall not allow visitors that are not criminally cleared inside the home during day care hours. Written declaration provided to Licensing by POC date of 1/30/24.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 01/29/2024 02:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/29/2024 at 01:54 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review the licensee did not comply with the section cited above in conducting disaster drills and having a current log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
1
2
3
4
Licensee shall provide proof of disaster drill to Licensing by POC date of 2/12/24
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and(record review, the licensee did not comply with the section cited above in maintaing an infant sleep log for C1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of Infant sleep log to Licensing by POC date.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 01/29/2024 02:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/29/2024 at 01:54 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in maintaing mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of mandated reporter training to Licensing by POC date
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in four daycare childrend did not have immunizaiton records for C1, C2, C4, and C5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of children's immunizations by POC date.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 01/29/2024 02:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/29/2024 at 01:54 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FARIA FAMILY CHILD CARE
FACILITY NUMBER: 367700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in having a roster for children in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of child/parent roster with physician's names to Licensing by POC date above.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obs, ervation, interview, and record review the licensee did not comply with the section cited above in one five month old infant in care C1 did not have LIC 9227 form in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
1
2
3
4
Licensee will provide proof of signed form by child's parents by POC date above.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
Page: 10 of 10