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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515405831
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:45:32 PM

Document Has Been Signed on 03/11/2024 03:45 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:DAHLSRUD, ANGELA FAMILY CHILD CARE HOMEFACILITY NUMBER:
515405831
ADMINISTRATOR:DAHLSRUD, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 770-1054
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
03/11/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Angela Dahlsrud - licenseeTIME COMPLETED:
04:00 PM
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On 3/11/2024 at 1:50pm, an annual inspection was made to the facility by Licensing Program Analysts (LPAs), E. Friese and B. Mendez. At 2:30pm the home was toured inside and outside. The licensee was supervising 3 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 6:15am-11:30pm , Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the laundry room and backyard, and were made inaccessible by door chain and deadbolt. The children use the front yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

4 children's records were reviewed at 1:59pm. 2 staff records were reviewed at 2:16pm. There is currently 1 adult living in the home.

The following deficiencies were cited: by record review, C2-C4 were missing immunizations, C4 was missing sleep logs, S1 was missing mandated reporter training, S2 was missing mandated reporter training, immunizations and employee rights (see LIC 809D).

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Elizabeth Friese
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: DAHLSRUD, ANGELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515405831
VISIT DATE: 03/11/2024
NARRATIVE
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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.

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.

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-andresources/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.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: DAHLSRUD, ANGELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515405831
VISIT DATE: 03/11/2024
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the licensee Angela Dahlsrud.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/11/2024 03:45 PM - It Cannot Be Edited


Created By: Elizabeth Friese On 03/11/2024 at 03:12 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: DAHLSRUD, ANGELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515405831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on record review, the licensee did not comply with the section cited above for C4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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2
3
4
Licensee will provided sleep log for C4 to CCLD by 3/15/2024.
elizabeth.friese@dss.ca.gov
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 2 files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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2
3
4
Licensee will provide mandated reporter certificates for S1 and S2 by 3/22/2024.
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:Erin Virrueta
LICENSING EVALUATOR NAME:Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/11/2024 03:45 PM - It Cannot Be Edited


Created By: Elizabeth Friese On 03/11/2024 at 03:12 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: DAHLSRUD, ANGELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515405831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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2
3
4
Licensee will provide S2's immunizations to CCLD by 3/22/2024.
elizabeth.friese@dss.ca.gov
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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2
3
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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2
3
4
Licensee will provide signed LIC 9052 to CCLD by 3/22/2024
elizabeth.friese@dss.ca.gov
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:Erin Virrueta
LICENSING EVALUATOR NAME:Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/11/2024 03:45 PM - It Cannot Be Edited


Created By: Elizabeth Friese On 03/11/2024 at 03:12 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: DAHLSRUD, ANGELA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515405831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 4 files. (C2-C4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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2
3
4
Licensee will provide immunizations to CCLD by 3/22/2024.
elizabeth.friese@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 infant's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
1
2
3
4
Sleep logs to CCLD by 03/11/2024
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:Erin Virrueta
LICENSING EVALUATOR NAME:Elizabeth Friese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
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