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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008976
Report Date: 06/26/2024
Date Signed: 06/26/2024 10:11:36 AM

Document Has Been Signed on 06/26/2024 10:11 AM - 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: 10CENSUS: 4DATE:
06/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Tina McMurry - LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced follow up Plan of Correction (POC) visit and met with Licensee (LS), Tina McMurry, for the purpose of addressing several outstanding type B deficiencies. On 06/03/24, LS was cited because at least one disaster drill had not been conducted within six months, LS's temporary absence exceeded 20 percent of the hours that the facility was providing care on 06/03/24, the facility did not furnish evidence of 15-minute checks for C1 & C2; and missing Individual Infant Sleep Plans (LIC 9227) for C4 & C4. Furthermore, the facility was missing evidence of negative Tuberculosis (TB) clearance and completion of AB 1207 Mandated Reporter Training and proof of immunity against Measles, Pertussis, and Influenza for S2, S2's record was missing Employee Rights (LIC 9052) and Acknowledgement of Requirement to Report Suspected Child Abuse (LIC 9108).

On 06/25/24, LS submitted a completed LIC 9098 and updated disaster drill log which reflected a disaster drill was conducted on 06/03/24 at 2:55pm, a written statement in which the Licensee acknowledged she exceeded 20 percent temporary absence and expressed she would comply with the requirements by not allowing her temporary absence to exceed 20 percent of the hours that the facility is providing care per day. LS also submitted completed LIC 9108, LIC 9052, proof of immunity against Pertussis and Influenza for S2, evidence to show that 15-minute checks were conducted from 06/03/24 through 06/20/24 for C1-C2 & C4-C5 and completed LIC 9227 for C3-C5. LPA noted evidence of negative TB clearance and proof of immunity against Measles and evidence of completion of AB 1207 Mandated Reporter Training (MRT) were still outstanding for S2.

During the visit, LPA observed four children in the care of LS and one staff (S1). LS furnished evidence to prove she made attempts to submit her POC in a timely manner, however, LS's computer experienced technical difficulties. According to LS's statement, S2 did not complete her MRT and did not obtain evidence of TB clearance and/or required Immunization Record, and as such, S2 would not work at the facility until those required items were obtained; and the deficiencies were cleared. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MCMURRY, TINA FCCH
FACILITY NUMBER: 483008976
VISIT DATE: 06/26/2024
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LS further explained that S2 made arrangements to obtain those items, LS requested an extension on her POC due date, and LS intends to submit evidence of S2's MRT to the Department by 07/18/24, as well as evidence of S2's TB clearance and proof of immunity against Measles by 07/31/24. LS understood that if she did not submit her POC by the due dates, the Department may assess civil penalties for not correcting the deficiencies. LPA cleared deficiencies related to California Code of Regulations (CCR) 102416.1(a)(10), 102417(a), 102417(g)(9)(A), 102425(a), 102425(c), and 102425(j)(1); and LPA provided LS with copies of the Letter of Deficiency Citations Cleared.

Exit interview conducted and report was reviewed with 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. There were no violation(s) of California Code of Regulations, Title 22; Division 12, observed during today’s visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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