<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008850
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:16:17 PM

Document Has Been Signed on 12/15/2023 01:16 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:ROERDEN, ALLISON FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008850
ADMINISTRATOR:ROERDEN, ALLISONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 718-7505
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
12/15/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Allison Roerden - LicenseeTIME COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Required - 3 Year inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 12/15/2023 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee 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 today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising 11 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 5:00PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the second floor, kitchen, dining areas, living room and garage, were made inaccessible by means of children’s safety gates. The staircase near the front entrance was barricaded with a child safety gate. The fireplace was made inaccessible by a child safety gate. The home was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification expire 10/05/2025. 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. The LPA verified firearm(s) and ammunition, and other dangerous weapon(s) were locked and stored separately. LPA did not observe any poison(s). LPA reviewed three staff (LS & S1-S2) records at 9:41am, which revealed S1’s AB 1207 Mandated Reporter Training certificate was expired, and S2’s record did not contain evidence of negative TB clearance.... (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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 5
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: ROERDEN, ALLISON FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008850
VISIT DATE: 12/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed five children’s (C1-C5) records at 10:16am which revealed C1-C5 records contained Identification and Emergency Information form (LIC 700), and Notification of Parent’s Rights (LIC 995A), Consent for Emergency Medical Treatment, Immunization Records (IR), and IRs were transcribed onto the blue CDPH 286. The Licensee did not furnish evidence to prove she carried an active liability insurance policy, and the C1-C5’s records did not contain a signed LIC 282. According to the facility’s disaster drill log, the facility conducted an emergency drill within the past six months and the last drill was documented on 11/17/23. The facility roster of the children in care was reviewed and appeared to be complete. During today’s visit, there were zero children under 24 months old present, and the Licensee confirmed she did not have any infants currently enrolled in care. A waiver was granted to allow a large pond in the front yard, the waiver was posted and the facility was complying with the conditions of the waiver.

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.

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/.

On this date, 12/15/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. (Continue to LIC 809-C)

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

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: ROERDEN, ALLISON FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008850
VISIT DATE: 12/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

Exit interview conducted and report was reviewed with the Licensee, Allison Roerden. 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. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/15/2023 01:16 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 12/15/2023 at 11:15 AM
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: ROERDEN, ALLISON FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

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
1
2
3
4
Based on the three staff (S1-S2 & LS) records reviewed at 10:16am which revealed S1's AB 1207 Mandated Reporter Training certificate was expired. 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: 01/02/2024
Plan of Correction
1
2
3
4
The Licensee stated she would ensure S1 completed the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee intends to submit a copy of S1's newly current certificate to the Department by 01/02/24 via mail, email or fax.
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
1
2
3
4
Based on the three staff (S1-S2 & LS) records reviewed at 9:41am which revealed S2's record was missing evidence of negative TB clearance. 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: 01/02/2024
Plan of Correction
1
2
3
4
The Licensee stated she would ensure S2 obtain evidence of negative Tuberculosis (TB) clearance and Licensee intends to submit evidence of S2's negative TB clearance to the Department by 01/02/24 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: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/15/2023 01:16 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 12/15/2023 at 11:29 AM
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: ROERDEN, ALLISON FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(1)
The licensee or registrant shall maintain one of the following: A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee not furnishing evidence of her current child care liability insurance and children's (C1-C5) record missing LIC 282. 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: 01/02/2024
Plan of Correction
1
2
3
4
Licensee stated she would either obtain and submit a copy of her active childcare liability insurance which meets the Department's requirements or she would provide the chlildren's parents with LIC 282 to notify parents the facility did not carry liability insurance.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5