WILLIAMS, CARMEN FAMILY CHILD CARE HOME

Based on staff record review, the licensee did not comply with the section cited above. During today's inspection, S1 did not furnish a signed copy of the employee rights for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated she would submit a singed copy of the employee rights for S3 to the Department by 12/10/21 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on records reviewed, the licensee did not comply with the section cited above. S2's record did not contain proof of immunity against the Measles, Pertussis and Infleunza, as well as S1 did not furnish record for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated the will obtain their proof of immunity against the Measles, pertussis and Influenza and she will submit copies of staff required immunization records to the Department by 12/10/21. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on records reviewed, the licensee did not comply with the section cited above. S1 did not furnish AB 1207 Mandated Reporter Training certificate for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated she will submit AB 1207 Mandated Reporter Training certificate for S3 by 12/25/21. Staff may complete the online training module at mandatedreporterca.com. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on record review, the licensee did not comply with the section cited above. LPA reviewed staff records at 12:00pm and records reviewed recvealed S2 was missing evidence of current TB clearance, as well as S1 did not furnish records for S3. which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated S2 and S3 would obtain proof of negative TB clearnance and submit evidence of TB clearance to the Department by 12/10/21 via mail. email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on records reviewed at 12:00pm, the licensee did not comply with the section cited above. During today's inspection, S1 did not furnish record for S3 or a copy of completed LIC 508 which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated she would submit completed LIC 508 for S3 and submit a copy of the completed LIC 508 to the Department by 12/10/21 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on interview, the licensee did not comply with the section cited above. During today's inspection, the facility representative did not furnish record for S1 which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated the facility would produce a file and records for S3 and would submit required records for S3 to the Department by 12/10/21 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on children's records reviewed, the licensee did not comply with the section cited above. Children's records reviewed revealed that C4, C5, C7, C8 and C9's either did not have a signed LIC 700 or the form was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S11 stated she would complete and/or obtain parental signature(s) on the LIC 700 and she would submit the completed and signed forms to the Department for C4, C5, C7, C8 and C9. The POC would be submitted to the Department via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on children's records reviewed, the licensee did not comply with the section cited above. Children's records reviewed revealed that C1 ad C5's immunization was not transcribed onto the CDPH 286. which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated the facility would obtain parental signature on LIC 627 for C1 and C5, and would submit copies of the LIC 627 with parental signature to the Department by 12/10/21 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099

Based on interview with the facility representative, the licensee did not comply with the section cited above. S1 did not furnish proof that 15 minutes checks were being conducted during infant's nap time, which poses/posed a potential health, safety or personal rights risk to persons in care.

Resolution: S1 stated she would produce a written statement detailing how the facility intends to conduct 15 minute checks and how the facility intends to comply with ccr 102425(j)(1), and will also complete lic 9098 to the Department by 12/10/21. LPA also provided S1 with a copy of a RO produced infant Sleep Log. The POC will be submitted to the Department by 12/10/21 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov Fax: 707-588-5099