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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008553
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:49:19 PM

Document Has Been Signed on 01/13/2023 02:49 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:BENEL, JUANA FCCHFACILITY NUMBER:
483008553
ADMINISTRATOR:BENEL, JUANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 642-1000
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 18CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Juana Benel - LicenseeTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit and met with Licensee, Juana Benel (LS), for the purpose of following on several outstanding POCs that were due by 01/10/23. On 12/20/22, the facility was cited seven potential risk violations for not furnishing evidence to prove that 15 minute checks had been conducted for children under 24 months old while they napped, LS & S1 were missing their required immunization, several children's records were either incomplete and various licensing forms such as LIC 282, 700 & 9150 was/were not signed by the child's parent(s), three children's (C3, C4 & C7) Immunization Records (IR) were not transcribed onto the blue CDPH 286; and children's records were not maintained or not furnished by the Licensee at the time of LPA's visit on 12/20/22.

During today's visit, LPA requested seven children's record, however; LS furnished six children's (C1, C2 & C4-C7) records. LS did not furnish record for C3 and a review of the children's records revealed C4 & C7 were missing evidence to prove they were immunized immunized against diseases as required by the California Code of Regulations, 102418(a). Records reviewed illustrated C1-C7 were missing licensing form 9150. During the visit, LS furnished a current AB 1207 Mandated Reporter Training certificate, a written statement from LS which indicated she understood the requirements to conduct and document 15 minute checks for children under 24 months old while they napped, required IR for S1. Furthermore, LS submitted completed licensing forms 282, 627, 700 for C1, and 282, 627, 995A for C7. LPA applied POCs to the outstanding deficiencies to clear some of the violations, and LPA provided LS with a copy of the Letter of Deficiency Citations Cleared.

The Licensee has requested for the Department to provide her with the opportunity to submit a full and complete record for C3 by 01/14/23, as well as she would submit IRs C3, C4 & C7 by 01/17/23. LS acknowledged and understood if she does not submit her POC by the POC due date, the license is subject to Civil Penalties of $100 daily for failure to correct.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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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: BENEL, JUANA FCCH
FACILITY NUMBER: 483008553
VISIT DATE: 01/13/2023
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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, Juana Benel. The were no violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s inspection.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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