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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008569
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:05:02 PM

Document Has Been Signed on 02/24/2023 03:05 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:BENSON, DOLORES FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008569
ADMINISTRATOR:BENSON, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 446-8829
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Dolores Benson - LicenseeTIME COMPLETED:
03:15 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 02/24/2023 indicates that all facility staff or other individuals who require caregiver background checks did not receive a criminal record and child abuse index clearances or exemptions. According to the Licensee’s (LS) statement, four adults including A1 resided in the home. LS stated A1 resided in the home since 01/01/23 and LS confirmed A1 was present during LPA's visit and LS had not submitted an updated Application (LIC 279) to notify A1 moved into the facility, and a review of Department records revealed A1 had not obtained an approved criminal record clearance prior to residing in the home and as such, an immediate civil penalty of $500 was assessed because LS did not ensure A1 obtain an approved criminal record clearance prior to residing 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. Licensee stated she was partnered with Child Start Inc.

During today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising seven children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30AM to 5:30PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire second floor, one bedroom on the first floor, kitchen, and the garage, and were made inaccessible by children's safety gates, plastic doorknob covers, and door locking mechanisms. The home was clean and orderly and was at a comfortable indoor temperature. The bottom of the staircase near the front entry door was barricaded with a child safety gate. The fireplace in the family room was screened with a child safety gate. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s EMSA approved pediatric CPR/First Aid certification expire 08/27/2024. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/24/2023 at 12:01 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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
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
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Based on Licensee's statement revealing A1 resided in the home since 01/01/23 and Department records confirming A1 had not obtained an approved criminal record clearance. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Licensee stated she would send A1 to get Livescan and Licensee would submit the completed LIC 9163 to the Department by 02/25/23 via email or fax. Email: melchisedeck.augustin@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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/24/2023 at 12:01 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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of three staff (LS, S1 & S2) at 10:28am which revealed LS, S1 & S2's records did not contain proof of immunity against the Influenza. 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: 03/10/2023
Plan of Correction
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Licensee stated she would obtain required immunization record for LS, S1 & S2, and Licensee would submit the required immunization records to the Department by 03/10/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of three staff (LS, S1 & S2) at 10:28am which revealed S1 & S2 were missing Employee Rights (LIC 9052). 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: 03/10/2023
Plan of Correction
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Licensee stated she would provided LIC 9052 to S1 & S2, and Licensee would submti evidence of the licensing forms signed by S1 & S2 by 03/10/23. 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: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/24/2023 at 12:01 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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

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 LPA's review of five children's (C1-C5) records at 10:59am, which revealed C1, C2, C3 & C5's Immunization Records (IR) were not transcribed onto the blue CDPH 286. 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: 03/10/2023
Plan of Correction
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Licensee stated she would review all the children's records and transcribe all required Immunization Records onto the blue CDPH, and Licensee would submit evidence of the children's transcribed IR on the CDPH 286 by 03/10/23. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of five children's (C1-C5) records at 10:59am, which revealed C1 & C2's records did not contained Licensing forms 995 or 627 that were required to be signed by parents. 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: 03/10/2023
Plan of Correction
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Licensee stated she would ensure C1 & C2's parents signed either the Licensing form 995 or 627, and the Licensee would submit copies of the signed forms to the Department by 03/10/23 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: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569
VISIT DATE: 02/24/2023
NARRATIVE
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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 fire extinguisher rated at least 2A10BC. LPA did not observe any poison(s) stored on the premise. Licensee stated she did not store any firearm(s) or other dangerous weapon(s) on site; and none were observed by LPA.

LPA reviewed three staff records (LS, S1 & S2) at 10:28am which revealed LS was missing proof of immunity against Influenza, S1 & S2’s records were missing Employee Rights (LIC 9052) and current AB 1207 Mandated Reporter Training certificates. Furthermore, the Licensee did not furnish evidence of negative TB clearance for A1.

LPA reviewed five children’s (C1-C5) records at 10:59am which included two children (C1 & C2) under 12 months old, and records reviewed revealed C1 & C2 were either missing LIC 627 or LIC 995, C1, C2, C3 & C5’s Immunization Records (IR) were not transcribed onto the blue CDPH 286. There were two portable cribs available for C1 & C2 to nap, and LS furnished evidence to prove she conducted 15-minute checks while C1 & C2 napped. The facility conducted an emergency drill with the past six months and the last drill was documented on 10/20/22. The facility roster of the children in care was reviewed and appeared to be complete. 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. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/24/2023 at 12:02 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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee's statement confirming A1 resided in the home and Licensee did not furnish evidence of negative TB clearance for A1. 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: 03/17/2023
Plan of Correction
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Licensee stated she would ensure A1 obtained evidence of negative TB clearance, and Licensee would submit evidence og A1's clearance to the Department by 03/17/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Type B
Section Cited
CCR
102416.2(a)(2)
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing to prove she an updated Application was submitted to notify the Department that A1 resided in the home. 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: 03/10/2023
Plan of Correction
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Licensee stated she would submit an updated Application (LIC 279) to the Department to reflect A1 moved in the home. 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: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569
VISIT DATE: 02/24/2023
NARRATIVE
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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. There following violations of the California Code of Regulations, Title 22; Division 12 were observed during today’s visit. Appeal Rights were provided.

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.



LPA, Melchisedeck Augustin informed licensee, Dolores Benson that this report dated 02/24/23 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA, Melchisedeck Augustin informed the licensee to provide a copy of this licensing report dated 02/24/23 that documents any Type A citation(s) 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 this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 02/24/2023 at 02:23 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: BENSON, DOLORES FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
(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 review of three staff (LS, S1 & S2) records at 10:28am which revealed S1 & S2's records did not contain 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: 04/10/2023
Plan of Correction
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Licensee stated she S1 & S2 would complete the AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee would submit current certificate of completion for S1 & S2 by 04/10/23 via mail, email or fax. Email: melchisedeck.augustin@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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


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