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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525407520
Report Date: 05/11/2022
Date Signed: 05/13/2022 09:03:44 AM

Document Has Been Signed on 05/13/2022 09:03 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MEDINA, ELIZABETH FAMILY CHILD CARE HOMEFACILITY NUMBER:
525407520
ADMINISTRATOR:MEDINA, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 209-1384
CITY:CORNINGSTATE: CAZIP CODE:
96021
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
05/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Elizabeth Medina TIME COMPLETED:
10:30 AM
NARRATIVE
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On 5/11/22, Licensing Program Analyst (LPA) Carrie Wisehart conducted a Case Management visit and met with licensee, Elizabeth Medina. The LPA discussed concerns brought up about children's play equipment being safe. The LPA also discussed reporting requirements. The licensee and S1 are current on Mandated Reporter training which was taken on 8/10/21. The LPA determined thru interviews with the licensee and Staff S1 had health / safety concerns regarding child(ren) in care which should have been reported under mandated reporting requirements.

The LPA during a tour of the facilities play equipment at 9:10 am, observed that the main play structure with the yellow slide had a loose nail sticking out; 4 sharp screw ends with approximately a 1/2 inch exposed and a loose board no longer attached on the top level and on the bottom level, a nail sticking out of a board approximately a 1/2". On the smaller play ground structure, the LPA observed multiple spider webs that need to be removed.

Witness (W1) indicated that on several occasions children came home with scraps and torn clothes after using the play equipment. The licensee confirmed that sometimes a child had used the play equipment and then presented with torn clothes but claimed she had looked the equipment over and could not find anything concerning.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Carrie Wisehart
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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Document Has Been Signed on 05/11/2022 10:30 AM - It Cannot Be Edited


Created By: Carrie Wisehart On 05/11/2022 at 09:29 AM
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: MEDINA, ELIZABETH FAMILY CHILD CARE HOME
FACILITY NUMBER: 525407520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
102417(d)

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Operation of a Family Child Care Home - The home shall provide safe toys, play equipment and materials.
This requirement was not met as evidenced by: Based on observation and interviews the play equipment had torn clothes and caused scratches.

This poses an immediate health, safety or personal rights risk to persons in care.
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The licensee will remove any loose nails/screws; will cover up exposed sharp ends of screws; will tighten up all screw connections; clean out spider webs and attach loose boards before children should use structure. Licensee will provide photo's by 5/12/22.
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Type B
05/18/2022
Section Cited
HSC1597.467(c)(1)

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Reporting Requirements 1597.467(c)(1) Any suspected child abuse or neglect, as defined in Penal Code Section 11165.6, of any child in care, in addition to reporting requirements pursuant to Penal Code Section 11166.
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Licensee will review reporting requirement regulations with staff and then each sign a statement that they understand reporting requirements. Both staff are current on Mandated Reporter training. Training to be completed and signed statements sent to CCL by 5/18/22.
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This requirement was not met as evidenced by: Based on observation and interviews the facility failed to report children who were coming to the program hungry every day.
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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:Megan Aviles
LICENSING EVALUATOR NAME:Carrie Wisehart
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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