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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008976
Report Date: 06/03/2024
Date Signed: 06/03/2024 02:18:27 PM

Document Has Been Signed on 06/03/2024 02:18 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:MCMURRY, TINA FCCHFACILITY NUMBER:
483008976
ADMINISTRATOR/
DIRECTOR:		MCMURRY, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 280-3742
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
06/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Kandis Alexander - Staff and Tina McMurry - LicenseTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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An Annual/Random inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 06/03/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Facility Representative 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. According to the Facility Representative, the facility was registered with the Resource and Referral Agency's, Food Program.


During today’s inspection, the home and grounds were toured. Licensee was not initially present during LPA's visit and S1 confirmed the Licensee left the facility around 8:00am, the facility's operating hours were 6:00am-6:00pm, Mon through Fri; and thus; the Licensee's absence exceeded 20 percent. It was noted the Licensee returned to the facility around 12:08pm. The Facility Representative and one staff (S2) were supervising eight children and was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are four bedrooms and two bathrooms on the second floor, and garage. These areas have been made inaccessible by means of a child safety gate. The children have access to the living, family room, dining areas, one bathroom and backyard. The staircase in the living room were barricaded with a child safety gate. The fireplace was securely screened. The home was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home and the Licensee understood that the facility telephone was required to stay at the facility during operating hours. Facility Representative’s EMSA approved pediatric CPR/First Aid certification expire 06/12/2025. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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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Document Has Been Signed on 06/03/2024 02:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/03/2024 at 11:31 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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of the disaster drill log which confirmed the facility did not conduct at least one emergency disaster drill within six months. 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: 06/20/2024
Plan of Correction
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Licensee stated she would conduct an emergency disaster drill, document the drill, and submit a copy of the updated drill log with completed LIC 9098, to the Department by 06/20/24 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on not enough crib(s) or play yard available for C1-C2 & C4-C5 to nap in. 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: 06/04/2024
Plan of Correction
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Licensee agreed to purchase a crib or play yard for each infant that is unable to climb out of a crib or play yard, and Licensee intends to submit evidence of additional play yards for infants to nap in, and her POC will be submitted by 06/04/24.
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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 06/03/2024 02:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/03/2024 at 11:31 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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations of the Licensee's absence exceeding 20 percent during the visit. 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: 06/20/2024
Plan of Correction
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Licensee stated she would ensure her absence(s) would not exceed 20 percent, and Licensee intends to submit a written statement detailing how she intends to comply with CCR 102417(a), and POC will be submitted to the Department by 06/20/24 via mail, email or fax.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Facility Representative not furnishing evidence to prove 15 minute checks were conducted while C1 & C2 took a nap. 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: 06/20/2024
Plan of Correction
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Licensee stated she would initiate 15 minute checks, document at least ten days worth of 15 minute checks on an infant sleep log, and Licensee intends to submit updated sleep log with completed LIC 9098 to the Department by 06/20/24 via mail, email or fax. 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/03/2024 02:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/03/2024 at 11:31 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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

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's review of two staff (S1 & S2) at 10:10am which revealed S2 was missing evidence of completion of AB 1207 Mandated Reporter Training. 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: 06/20/2024
Plan of Correction
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Licensee stated she would ensure S2 completed the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee intends to submit a copy of S2's current certificate to the Department by 06/20/24 via mail, email or fax.
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 two staff (S1 & S2) at 10:10am which revealed S2 was missing LIC 9052 and LIC 9108. 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: 06/20/2024
Plan of Correction
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Licensee stated she would provide and obtain S2's signatures on LIC 9052 and LIC 9108, and Licensee intends to submit evidence of the signed forms to the Department by 06/20/24 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 06/03/2024 02:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/03/2024 at 11:31 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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on two staff (S1 & S2) records reviewed at 10:10am which revealed S2 was missing proof of immunity against Measles, Pertussis and 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: 06/20/2024
Plan of Correction
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Licensee stated she would ensure S2 obtained evidence of immunity against Measles, Pertussis and Influenza, and Licensee intends to submit evidence of S2's required immunization record by 06/20/24 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on six children's records reviewed at 10:27am which revealed C4 & C5 were missing LIC 9227. 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: 06/20/2024
Plan of Correction
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LPA provided Licensee with blank LIC 9227 and Licensee said she would ensure C4-C5's parents completed and signed the forms, and Licensee intends to submit evidence of C4-C5's completed forms to theDepartment by 06/20/24 via mail, email or fax.
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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


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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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976
VISIT DATE: 06/03/2024
NARRATIVE
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LPA did not observe any poison(s). There is a functional smoke and carbon monoxide detectors, and a fully charged fire extinguisher that met the standards of the state fire marshal. There was an in-ground swimming pool and hot tub in the backyard, and bodies of water were fenced by a mesh fencing that was at least five feet in height and met fencing requirements.

According to the facility’s disaster drill log, the facility did not conduct at least one emergency disaster drill within six months. The facility roster of the children in care was reviewed and appeared to be complete. LPA reviewed two staff records at 10:10am which revealed S2 was missing evidence of negative TB clearance and proof of immunity against Measles, Pertussis and Influenza, and Employee Rights (LIC 9052) and LIC 9108. Furthermore, S2’s record was missing evidence of completion for AB 1207 Mandated Reporter Training. LPA reviewed six children’s (C1-C6) records at 10:27am which revealed C1 & C2 were missing evidence to prove 15 minute checks had/were conducted while the children napped and C4-C5’s record were missing Individual Infant Sleep Plans (LIC 9227). LPA observed one crib but there were four children (C1-C2 & C4-C5) under 24 months old present, and according to S2’s statement, C1-C2 & C4-C5 were unable to climb out of a crib or play yard.



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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. (Continue to LIC 809-C)

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

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
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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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976
VISIT DATE: 06/03/2024
NARRATIVE
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LPA requested a Plan for Providing IMS from the Licensee. 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 Facility Representative, Kandis Alexander and Licensee, Tina McMurry. 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 California Code of Regulations, Title 22; Division 12, were observed during today’s visit. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 06/03/2024 02:18 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 06/03/2024 at 12:40 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: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

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 LPA's review of two staff (S1 & S2) at 10:10am which revealed S2 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: 06/20/2024
Plan of Correction
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Licensee stated she would ensure S2 obtained evidence of negative TB clearance and Licensee intends to submit that evidence to the Department by 06/20/24 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
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