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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007352
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:17:04 PM

Document Has Been Signed on 09/19/2024 01:17 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BLAIR, JENNIFER FCCHFACILITY NUMBER:
483007352
ADMINISTRATOR/
DIRECTOR:		BLAIR, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 553-8733
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
09/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Jennifer BlairTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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An unannounced annual/random inspection was made to the facility by Licensing Program Analyst (LPA), Cindy Castro. LPA met with Jennifer Blair, Licensee (L1). There are currently five adults living in the home. L1 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 5 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.

During the inspection the home was toured inside and outside. The licensee (L1) and two Staff were supervising nine children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:30AM to 5:30PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the four bedrooms and two bathrooms, living/dining area, kitchen, and garage, and were made inaccessible by means of a children safety gate. The top of the staircase near the living room was barricaded with a child safety gate. The fireplace was screened with a child safety gate. The home was clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The backyard is used as the outdoor play area, it is fully fenced. There is a hot tub that is covered and securely locked on all corners and the hot tub was fully enclosed in wrought iron fencing that was at least five feet in height and met fencing requirements. There were no other bodies of water observed in the yard. There is a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Licensee stated that there are no poisons kept in the home. There is a working smoke detector, carbon monoxide detector and fire extinguisher rated at least 2-A, 10: BC. Last conducted and documented emergency/fire drill was on 06/14/24. Licensee stated that there are no firearms or weapons in the home, none were observed during today’s visit. Five child files were reviewed and current. Facility roster was reviewed and current. (Continue to LIC 809-C)

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BLAIR, JENNIFER FCCH
FACILITY NUMBER: 483007352
VISIT DATE: 09/19/2024
NARRATIVE
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At 10:02am LPA requested records for two staff (S1 & S2), however; Licensee did not furnish staff records. L1 did not furnish current AB 1207 Mandated Reporter Training certificate and Pediatric CPR/First Aid certification for S1 & S2. Licensee’s pediatric CPR/First Aid certification expires on 11/08/24. Licensee’s mandated reporter training certification expires 10/13/24.

LPA discussed 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)/ (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/

Licensee was informed of the MyChildCarePlan.org website; 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.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 09/19/24.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BLAIR, JENNIFER FCCH
FACILITY NUMBER: 483007352
VISIT DATE: 09/19/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

The following violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s visit. Appeal Rights were provided.

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.

An exit interview was conducted and reviewed with the Licensee, Jennifer Blair whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/19/2024 01:17 PM - It Cannot Be Edited


Created By: Cindy Castro On 09/19/2024 at 12:22 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: BLAIR, JENNIFER FCCH
FACILITY NUMBER: 483007352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

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
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Based on LPA observations at 10:02am of the Licensee's (LS) and S1-S2 requested records. L1 did not furnishing a current Mandated Reporter Training certification for S1-S2. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee stated S1 and S2 would complete Mandated Reported Training Certification on mandatedreporterca.com. Licensee will submit proof to the department of Mandated Reporter Training certificates for S1 and S2 by 10/04/24 via mail, email or fax. Email: cindy.castro@dss.ca.gov & Fax: 707-588-5099
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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Licensee did not furnishing a current EMSA approved Pediatric CPR/First Aid certification for S1 and S2. L1 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: 10/11/2024
Plan of Correction
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Licensee stated S1 and S2 would enroll in an EMSA approved Pediatric CPR/First Aid training, complete the training and submit a copy of staffs current certification to the Department by 10/11/24 via mail, email or fax. Email: cindy.castro@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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/19/2024 01:17 PM - It Cannot Be Edited


Created By: Cindy Castro On 09/19/2024 at 12:22 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: BLAIR, JENNIFER FCCH
FACILITY NUMBER: 483007352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Staff Records reviewed at 10:02am Licensee did not furnish records for S1 or S2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee stated she would produce personnel record for S1 and S2. Licensee will submit proof of complete staff files for S1 and S2 to the department by 10/11/24 via mail, email or fax. Email: cindy.castro@dss.ca.gov & Fax: 707-588-5099.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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