Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393617334
Report Date: 11/14/2016
Date Signed 11/14/2016 12:56:42 PM

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:HAMILTON, MONICAFACILITY NUMBER:
393617334
ADMINISTRATOR:HAMILTON, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 751-6857
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:14CENSUS: 3DATE:
11/14/2016
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Steven Hamilton TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emerita Curiel met with licensee's husband, Steven Hamilton regarding a case management / POC visit. Licensee's husband was the only adult present at the time of the visit, the adult is fingerprint cleared but did not have a CPR/First Aid Certificate. Licensee was not present at the time of the visit. LPA toured the facility inside and out; LPA observed 3 preschool age children. LPA spoke with licensee Monica Hamilton on the phone and verified she did not complete CPR/First Aid class and does not have a current CPR/First Aid certificate.

LPA observed the playground was not safe and was broken.

Deficiencies are cited on the subsequent page 809-D of this report under the California Code of Regulations, Title 22.The licensee was provided a copy of their appeal rights.

Exit interview conducted. LPA read and explained the report. Notice of Site Visit was provided.

SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Emerita CurielTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HAMILTON, MONICA
FACILITY NUMBER: 393617334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2016
Section Cited
102416(c)
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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.Licensee did not complete her CPR/First Aid class. Husband was left alone with children and did not have CPR/First Aid Certificate.
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Licensee stated she will send CCL a copy of her current CPR card by 12/14/16.
Type B
12/14/2016
Section Cited
102417(d)
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Operation of a Family Child Care Home. The home shall provide safe toys, play equipment and materials.
LPA observed the outdoor playground slide was broken and was not safe for children to play.
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Licensee stated the children are not allowed to play on the slide and she will replace the playground slide by POC 12/14/16.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Emerita CurielTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
LIC809 (FAS) - (06/04)
Page: 2 of 2