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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573621840
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:33:17 PM

Document Has Been Signed on 08/17/2022 01:33 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CARING CONNECTION CHILDREN'S CENTERFACILITY NUMBER:
573621840
ADMINISTRATOR:FRISTOE, MELANIEFACILITY TYPE:
830
ADDRESS:703 WESTACRE ROADTELEPHONE:
(916) 899-9121
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 11TOTAL ENROLLED CHILDREN: 11CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lauren GarciaTIME COMPLETED:
01:45 PM
NARRATIVE
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On 08/17/2022 at 8:30 AM, Licensing Program Analysts (LPAs) Tiffanie Diep and Chayntel Hunter met with Director Lauren Garcia for the purpose of a case management inspection.

LPAs were notified that an incident had occurred where a child had injured themselves on 08/08/2022. Director stated that the child received medical attention, but a review of records determined the incident was not reported to the Department. Director also stated that the incident was not documented and only communicated with the child’s parent verbally.

LPA informed Director that incidents resulting in injury requiring medical attention are required to be reported to the Department within 24 hours and an Unusual Incident Report must be submitted to the Regional Office within seven days. Title 22 regulations are being cited on the subsequent 809-D page.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 08/17/2022 01:33 PM - It Cannot Be Edited


Created By: Tiffanie Diep On 08/17/2022 at 12:45 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CARING CONNECTION CHILDREN'S CENTER
FACILITY NUMBER: 573621840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited
CCR
101212(d)(1)(B)

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Reporting Requirements: (d) Upon the occurrence...of any of the events below…a report shall be made to the Department…within...the next working day... and a written report…shall be submitted...within seven days...(1) Events reported shall... include... (B) Any injury... that requires medical
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LPA discussed reporting requirements with Director. Director stated she understood and will submit a written Unusual Incident Report via e-mail or fax to LPA by 09/16/2022. Director stated she will report all future incidents to the Department within the specified timeframe.
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attention. This requirement was not met as evidenced by: A review of records determined that an incident occurred on 08/08/2022 requiring medical attention that was not notified to the Department. This is a potential health and safety risk to children in care.
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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:Jeanne Smith
LICENSING EVALUATOR NAME:Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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