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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483005891
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:54:18 PM

Document Has Been Signed on 01/17/2023 03:54 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:ALL DAY FUN & PLAY CENTER - INFANTFACILITY NUMBER:
483005891
ADMINISTRATOR:DE LOVE, SHARISEFACILITY TYPE:
830
ADDRESS:2220 PENNSYLVANIA AVENUETELEPHONE:
(707) 399-8386
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
01/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Center Director Heidi BeardenTIME COMPLETED:
03:50 PM
NARRATIVE
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Through the course of investigation, LPA conducted an infant record review and found three infants out of four did not have an admissions agreement completed on file. Three infants’ admissions agreement did not indicate; what basic services they were to receive from the center, or the payment provisions per regulation. Licensee acknowledged she does not give the admission agreement to guardians, some guardians take a picture of the agreement but don’t ask for a physical copy of it. Licensee believed having a signed admissions agreement was sufficient in the infants file. LPA printed Admissions agreement regulation and reviewed it with center director, comparing the completed admissions agreement of one infant with the three incomplete admissions agreements.

The California Code of Regulations, Title 22, Division 12 & Chapter 1, section 101219 (a) Is being cited on 809-D. Exit Interview was conducted, report was reviewed with center director. Notice of site visit was given and must remain posted for 30 days. Appeal rights were given.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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 01/17/2023 03:54 PM - It Cannot Be Edited


Created By: Elpidia Hernandez Torres On 01/17/2023 at 03:21 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: ALL DAY FUN & PLAY CENTER - INFANT
FACILITY NUMBER: 483005891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited
CCR
101219(a)

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(a) The licensee and the child's authorized representative shall jointly complete a current individual written admission agreement for the child. This documentation shall be maintained at the child care center and shall be available for review.
This was not met as evidence by. . . .
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Licensee has agreed to email the addmisions agreement of four currently enrolled infants to LPA Hernandez Torres by 01/31/2023. Licensee has agreed to complete admissions agreements with guaridans prior to a child's first day.
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Based on record review and interviews three out of four admissions agrements were incomplete missing signitures, basic services (the date/times the child would attend the day care), payer provisions, ( the amount for tuition and who is paying). This poses a potential health and safty risk to children 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:Leslie Lepori
LICENSING EVALUATOR NAME:Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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