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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480112064
Report Date: 02/04/2022
Date Signed: 02/04/2022 02:10:53 PM

Document Has Been Signed on 02/04/2022 02:10 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ARMSTRONG, LORRAINE FAMILY CHILD CARE HOMEFACILITY NUMBER:
480112064
ADMINISTRATOR:ARMSTRONG, LORRAINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 643-3180
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lorraine Armstrong - LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 02/04/2022 indicates that all facility staff or other individuals who require caregiver background checks receive a criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During today’s inspection the home and grounds were toured. The Licensee (LS) was supervising five children (C1-C5) and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 6:00AM to 6:00PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are four bedrooms, one bathroom, and were made inaccessible by door latch, plastic doorknob covers, and door locking mechanism. The home was clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification expire on 08/05/2022. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged 2A10BC fire extinguisher at the facility. Poison(s) were stored and locked in an outdoor shed.

During today’s inspection, LPA observed one infant under 24 months old in care and there were two pack and plays available. The Licensee claimed there were a total of two infants enrolled into care. The pack and plays contained a frame enclosed with integrated mesh or fabric sides. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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 02/04/2022 02:10 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/04/2022 at 12:17 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARMSTRONG, LORRAINE FAMILY CHILD CARE HOME
FACILITY NUMBER: 480112064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on children's records reviewed at 10:51am and Licensee not furnishing proof that 15 minutes checks had were being conducted for C5 & C6. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2022
Plan of Correction
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Licensee stated she was already checking on the napping infant(s), however; she would immediately start to document her 15 minutes of the napping infant(s) upt to 24 months old and Licensee would submit evidence of implementation of Sleep Log for C5 & C6 and written statement detailing her implementation of 15 minutes checks. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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
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Based on LPA's interview with the Licensee and the Licensee not furnishing a current AB 1207 Mandated Reporter Training certificate. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
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Licensee stated she would obtain a current AB 1207 Mandated Reporter Training certificate or complete the online training module at, mandatedreporterca.com, and she would submit her current certificate to the Department by 03/21/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/04/2022 02:10 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/04/2022 at 12:17 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARMSTRONG, LORRAINE FAMILY CHILD CARE HOME
FACILITY NUMBER: 480112064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on children's records reviewed at 10:51am which revealed C1-C6's records either did not contain Immunization Record (IR) that were transcribed onto the blue CDPH 286 or transcribed CDPH 286 were missing. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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The Licensee stated she would obtain children's current immunization records (ir) and she would transcribe the ir on the blue CDPH 286, and Licensee would provide evidence that children were immunized, as well as the transcribed CDPH 286 to the Department by 02/18/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102425(c)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on children's records reviewed at 10:51am which revealed that C6's record did not contain a completed LIC 9227. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
POC Due Date: 02/10/2022
Plan of Correction
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Licensee stated she would provide the LIC 9227 to C6's authorized representative to complete and Licensee would submit the a copy of the completed LIC 9227 and a written statement detailing how she intended to comply with CCR 102425(c) to the Department by 02/10/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ARMSTRONG, LORRAINE FAMILY CHILD CARE HOME
FACILITY NUMBER: 480112064
VISIT DATE: 02/04/2022
NARRATIVE
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LPA reviewed six children’s (C1-C6) records at 10:51am and records reviewed contained identification and emergency information forms, parents’ rights, the children’s Immunization records (IR), however; C1-C6’s records either did not contain or were missing transcribed CDPH 286. C6’s record also did not contain a completed LIC 9227, as well as the Licensee did not furnish proof that 15 minutes checks had been conducted for C5 and C6. LPA requested a current AB 1207 Mandated Reporter Training certificate, however; LS did not furnish a current certificate for review. (Continue to LIC 809-C)

The facility conducted an emergency drill on 02/04/22. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee stated there were no firearms and/or other dangerous weapons in the home, and none were observed. There were no pools or other bodies of water observed. The facility is not providing Incidental Medical Services (IMS) to children in care.

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. 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. 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.

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 conducted and report was reviewed with the Licensee. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ARMSTRONG, LORRAINE FAMILY CHILD CARE HOME
FACILITY NUMBER: 480112064
VISIT DATE: 02/04/2022
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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