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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010129
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:09:38 PM

Document Has Been Signed on 11/01/2023 01:09 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: 10DATE:
11/01/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Crystal Cleveland - LicenseeTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Plan of Correction (POC) visit and met with Licensee (LS), Crystal Cleveland to follow up on prior outstanding deficiencies.

On 10/12/2023, LS was cited five Type B deficiencies because an electrical outlet with exposed wires in the patio and patio was missing latches on the door to prevent access to the main yard, and another designated section of the yard had broken plastic and debris scattered, LS did not furnish evidence to prove she initiated 15 minute while a child (C1) under 24 months took a nap, not conducting an emergency disaster drill within six months, LS was missing proof of immunity against Pertussis and five children's (C1-C5) Immunization Records (IR) were not transcribed onto the blue CDPH 286. On 10/22/23, the Licensee submitted evidence which showed the backyard had been cleaned up, the electrical outlet was securely covered and the latches on the door to prevent access to the main yard, had been installed. Furthermore, LS submitted evidence showing she initiated 15-minute checks for C1, provided an updated disaster drill log reflecting she conducted a fire drill on 10/13/23, and transcribed CDPH 286 for C1-C5. It is noted that the CDPH 286 for C1-C5 were incomplete.

During today's visit, LPA counted ten children which consisted of two children under 24 months old. LS furnished evidence of 15-minute checks for both infants and required staff immunization record for herself and provided fully transcribed CDPH 286 for C1-C5. The patio door was missing a latch, however; LS re-installed the latch prior to LPA's departure. LPA cleared the deficiencies mentioned and provided the Licensee with the letters of deficiencies citations cleared.

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. There were no violation(s) of the 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: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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