Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490170978
Report Date: 06/11/2015 12:00:00 AM
Date Signed 06/11/2015 01:56:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VOGT FAMILY DAY CARE-JODYFACILITY NUMBER:
490170978
ADMINISTRATOR:VOGT, JODYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 578-0549
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:14CENSUS: 10DATE:
06/11/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:JodyTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Kevin O'Connell made an unannounced visit for the purpose of inspecting for compliance with Title 22 regulations for this Annual/Random inspection. Present were Licensee, minor son Zion, assistants Felicia, Marcene, 14 year old Trinity, 3 infants, 5 pre school children and 2 school age children.
Licensee and one minor son currently live in the home. (all adults are fingerprint cleared).
Hours of operation are 7 - 5:30 M-F.
LPA's toured facility inside and out. There are two dog and two cats. Shots are said to be current.
The entire home, including a converted garage is used for care. The backyard is used by children and is completely fenced.
Email address was obtained. Required postings were posted.
Pediatric First Aid & CPR are current. Fire drills and the children's roster were not current today.
One smoke alarm was tested and is operational. The fire extinguisher located in the play room is fully charged. Five children's files were reviewed for Identification & Emergency Information, Consent for Medical Treatment and Immunization forms. One assistant's file was reviewed today.
Sharps were inaccessible. Licensee states that there are no guns or dangerous weapons in the home and none were observed.
No pools, trampoline, fountains or other bodies of water were present. First aid supplies are stored in the play room.
Poisons are key locked in a shed in the back yard. There is no fireplace.
Cleaning supplies are inaccessible and stored in cabinets with latches.
Vitamins and medications are inaccessible. No exersaucers, baby walkers, or Johnny Jump-ups. Licensee does not carry liability insurance and has signed affidavits in the children's files. There is a working phone.
SUPERVISOR'S NAME: Linda WalkerTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2015
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VOGT FAMILY DAY CARE-JODY
FACILITY NUMBER: 490170978
VISIT DATE: 06/11/2015
NARRATIVE
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Applicant understands & agrees during hours of operation: no smoking on the premises; child care must be provided in the "primary" residence; all adults working or residing in the home are required to be fingerprint & TB cleared; required vehicle restraints will be used when transporting children; only adults with a criminal record clearance can transport children; children will never be left alone unaccompanied in a vehicle & children shall not be allowed to sleep in car carriers in the home. Fingerprinting, exemption, and exclusion requirements and inspection authority were reviewed.
Fire drills must be conducted twice a year and be documented. A current roster must be maintained and available to licensing staff upon request. Children's records including evidence of current immunizations, personal rights and parents rights must be maintained and available for review as needed.
Absences shall not exceed 20 % of the hours that the facility is providing care.

The licensee understands the responsibility of securing copies of forms and regulations from the web site http://www.ccld.ca.gov.
Civil Penalties: 1. Immediate $100 civil penalty (per day for up to 5 days) for adults working or residing in the home without a criminal record clearance. 2. Immediate $50 civil penalty for not disclosing, when asked, that a person working or residing in the home received a criminal record exemption. 3. Immediate $150 civil penalty for: absence of supervision (a child left unattended or alone with a person under 18 years of age or wandered away due to lack of supervision); accessible bodies of water; accessible firearms, ammunition, or both; refused entry to a facility or any part of a facility; and the presence of an excluded person on the premises. 4. A $150 per day for every day violations listed in #3 are not corrected.
This and all licensing reports are subject to management review.
Information was given on:
Play yard (pack-n-play) standards; Sunscreen updates; Criminal background check transfer requirements; CPR and First Aid renewal requirements; Car seat safety laws; Baby walkers, Exersaucers, Infant bouncers, Johnny jumpers; Capacity/ ratio requirements; 2012 crib standards.

See 809D for deficiency .


Appeal Rights were given.
Notice of Site Visit posted.
SUPERVISOR'S NAME: Linda WalkerTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2015
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VOGT FAMILY DAY CARE-JODY
FACILITY NUMBER: 490170978
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2015
Section Cited
102417(g)9a1
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102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.

The fire drill log & roster were not current today.
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Licensee states that she will provide proof of correction of the fire drill log and roster to LPA by 6/22/15.

Fax 707 588- 5099
kevin.oconnell@dss.ca.gov
Type B
06/22/2015
Section Cited
102418(g)& (h)1
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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
102418(g)(h) (1) The family day care home shall record each pupil's immunization on the California School Immunization Record, PM 286 (6/95).
Two children's files were missing PM286 (blue card) today.
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Licensee states that she will provide proof of correction to LPA by 6/22/15.

Fax 707 588- 5099
kevin.oconnell@dss.ca.gov
Type B
06/22/2015
Section Cited
102416(a)
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102416 Personnel Requirements
(a) The licensee shall provide each employee with a copy of the Notice of Employee Rights (LIC 9052 (4/88)) form furnished by the Department.
(1) Each employee shall be requested to sign
nd date the notice form acknowledging receipt.
Assistant's file was missing LIC 9052, LIC 9108 and LIC 508 and TB clearance.
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Licensee states that she will provide proof of correction to LPA by 6/22/15.

Fax 707 588- 5099
kevin.oconnell@dss.ca.gov
Type B
06/22/2015
Section Cited
102416(c)
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102416(c) 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's CPR and First Aid cards were not available at visit.
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Licensee states that she will provide proof of confirmation of enrollment in Pediatric First Aid and CPR classes to LPA by 10/22/14.
Licensee will also send pictures of the CPR and First Aid cards front and rear when they become available.
kevin.oconnell@dss.ca.gov
fax 707 588-5099
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: Linda WalkerTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3