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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010129
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:03:07 PM

Document Has Been Signed on 10/12/2023 04:03 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:CLEVELAND, CRYSTAL FCCHFACILITY NUMBER:
483010129
ADMINISTRATOR:CLEVELAND, CRYSTALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 725-1213
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 8DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Crystal Cleveland - LicenseeTIME COMPLETED:
04:10 PM
NARRATIVE
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A required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 10/12/2023 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) was supervising eight 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 5:00AM to 5:30PM & 6:00pm-11:00pm, Mon–Sat. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire second floor, kitchen, laundry room, and garage, and were made inaccessible by means of a children’s safety gates. The staircase in the living room was barricaded with a child safety gate. The fireplace was screened with a child cubby. The home was at a comfortable indoor temperature of 73 degrees Fahrenheit. There were safe toys available for children. There is a working telephone in the home. Licensee’s EMSA approved pediatric CPR/First Aid certification expire 04/04/2024. 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. Licensee stated she did not store firearm(s) or other dangerous weapon(s) on the premise. LPA did not observe any poison(s). Licensee furnished a copy of her current AB 1207 Mandated Reporter Training certificate, however; Licensee was missing proof of immunity against Pertussis. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 6
Document Has Been Signed on 10/12/2023 04:03 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 10/12/2023 at 02:28 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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of an eletrical outlet with exposed wires in the patio and patio was missing latches on the door to prevent access to the main door, and another designated section of the yard had broken plastic and debris scattered. 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: 10/23/2023
Plan of Correction
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Licensee stated she would clean the backyard, installed safety latches on the patio doors to prevent access to off limit main yard, and she would ensure the electrical outlet was covered with plastic caps, and the exposed wires were inaccessible. Licensee intends to submit evidence of POC by 10/23/23.
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 review of the facility's disaster drill log which indicated the facility did not conduct an emergency disaster drill within the past 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: 10/23/2023
Plan of Correction
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Licensee agreed to conduct an emergency disaster drill and submit evidence showing a current drill was conducted, along with LIC 9098 to the Department by 10/23/23 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: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/12/2023 04:03 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 10/12/2023 at 02:28 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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing evidence to prove she did/had conducted 15 minute checks while C1 napped. The licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Licensee agreed to complete and document .. days worth of 15 minute checks, and Licensee intends to submit evidence showing initiation of 15 minute checks for C1 to the Department by 10/23/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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 record review which revealed that the Licensee was missing proof of immunity against Pertussis. 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: 10/23/2023
Plan of Correction
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Licensee stated she would obtain her proof of immunity against Pertussis and Licensee intends to submit the evidence to the Department by 10/23/23 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: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/12/2023 04:03 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 10/12/2023 at 02:28 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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023

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 five children's (C1-C5) records reviewed at 1:38pm which revealed C1-C5's Immunization Records 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: 10/23/2023
Plan of Correction
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Licensee stated she would transcribe the children's Immunization Records (IRs) on the blue CDPH 286, and the Licensee would submit completed CDPH 286 and IRs for C1-C5. 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: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129
VISIT DATE: 10/12/2023
NARRATIVE
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Two patio doors are missing children’s safety latches to prevent children from entering the main yard that is off limits and an electrical outlet was loose from the wall and had exposed wires, and another section of the yard was designated for the children’s outdoor play area which had broken plastic which appeared sharp.

LPA reviewed five children’s (C1-C5) records at 1:38pm which revealed the records contained Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information form (LIC 700), Parent Notification of Additional Children in Care (LIC 9150), and Notification of Parent’s Rights (LIC 995A), however; C1-C5's Immunization Records (IRs) were not transcribed onto the blue CDPH 286. According to the facility’s disaster drill log, the facility did not conduct an emergency drill within the past six months and the last drill was documented on 04/04/22. The facility roster of the children in care was reviewed and appeared to be complete. There were no bodies of water observed. The Licensee stated she currently had two children under 24 months old enrolled into care, and one infant (C1) was present during LPA’s visit. There were five play yards available for infants to use, and the Licensee did not furnish evidence to prove she did/had conducted 15-minute checks while C1 took a nap.

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.


During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. On this date, 10/12/2023, 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: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010129
VISIT DATE: 10/12/2023
NARRATIVE
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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.
The Licensee provided proof of control of property.

Exit interview conducted and report was reviewed with the Licensee, Crystal Cleveland. 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. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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