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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010601
Report Date: 08/30/2024
Date Signed: 08/30/2024 05:16:02 PM

Document Has Been Signed on 08/30/2024 05:16 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:CLEVELAND, CRYSTAL FCCHFACILITY NUMBER:
483010601
ADMINISTRATOR/
DIRECTOR:		CLEVELAND, CRYSTALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 725-1213
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
08/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Crystal Cleveland - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management visit and met with Licensee (LS), Crystal Cleveland, for the purpose of confirming health and safety accommodations of the children in care. Upon LPA's initial arrival, there were eight children napping in the family room area, and the children did not appear to be in any distress, and LPA did not observe any violation(s) of personal rights. The children were initially in the care of one staff (S1) which possessed a current pediatric cardiopulmonary Resuscitation certification that was not approved by the Emergency Medical Services Authority (EMSA). The Licensee furnished a copy of her pediatric CPR/First Aid certification which expire on 06/08/26, however; the Licensee did not furnish evidence of completion for AB 1207 Mandated Reporter Training certificates for herself and S1.

A review of staff records on 08/30/2024 indicates 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.

The fireplace was screened by a large television and the staircase near the front entrance were barricaded with retractable child safety gate. Parents Rights and license were posted on a parent board on a wall in the family room. LPA did not observe any accessible hazards. LPA interviewed three children (C1-C3) which confirmed they had not been harmed and they felt safe at the facility. Based on LPA's observations, there were no health and safety concerns. Licensee did not furnish evidence to prove 15 minute checks were conducted for C6 & C7 within the past 30 days. LPA consulted with LS on personal rights and Licensee confirmed she understood and acknowledged the requirements of children's personal rights. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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: CLEVELAND, CRYSTAL FCCH
FACILITY NUMBER: 483010601
VISIT DATE: 08/30/2024
NARRATIVE
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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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 05:16 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 08/30/2024 at 04:25 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: 483010601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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.
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Licensee stated she would ensure all staff including herself and S1, complete the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee intends to submit evidence of completion & copies of certificates for staff to the department by 09/10/24.
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This requirement was not met as evidenced by: Based on Licensee not furnishing evidence of current completion on AB 1207 Mandated Reporter Training for herself and S1. This poses a potential health, safety and/or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
09/10/2024
Section Cited
CCR102425(j)(2)(D)(c)

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Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check.
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Licensee said she would conduct and document at least five days worth of 15 minutes checks for all C6-C7, and Licensee intends to submit evidence of 15 minute checks to the department by 09/10/24.
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This requirements was not met as evidenced by: Based on Licensee not furnishing evidence of 15 minute checks within past 30 days. This posed/poses a potential health, safety and/or personal rights risk to children in care.
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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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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