<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610329
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:02:18 PM

Document Has Been Signed on 07/29/2021 12:02 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SAM, ANA FAMILY CHILD CAREFACILITY NUMBER:
136610329
ADMINISTRATOR:ANA SAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 970-1020
CITY:CALEXICOSTATE: CAZIP CODE:
92231
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ana SamTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On July 29, 2021, at 10:15 a.m., Licensing Program Analyst (LPA), Gloria Gonzalez conducted an unannounced Annual Required Inspection and met with the Licensee, Ana Sam.  LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee.  Two (2) children and Two (2) staff were present in the facility during this inspection.  This facility is a 2 story, 4 bedroom, 3 bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: Living room, dining room, TV room, kitchen, bathroom #1, back yard patio.  Off limits areas are all of upstairs (bedrooms #2, #3, #4, bathroom #2, #3), bedroom #1, garage, backyard pool and play house area, and laundry room and are inaccessible through use of a safety gate and door knob covers.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements.  Hazardous items were made inaccessible to children during the inspection.  The licensee has toys, play equipment and materials available.  The home has a fenced patio available for outdoor activities. The upstairs is not used and is gated off at the bottom of the stairway and the applicant understands the gate must be in place when children under five years are present during day care hours. The pool is made inaccessible to children by a fence as required by regulation. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances. Licensee’s First Aid and CPR certifications expire on 12/2021.  Licensee has required immunization's.  Licensee completed Mandated Reporter Training on 2/25/21. Facility roster is maintained and was reviewed.  The last fire and disaster drills were conducted and documented on 7/5/21. 

LPA provided and discussed the following:  Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances.  Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.  Licensee was also provided information regarding Safe Sleep Regulation Section 102425, SIDS, Lead exposure and Shaken Baby Syndrome.  LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. 
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SAM, ANA FAMILY CHILD CARE
FACILITY NUMBER: 136610329
VISIT DATE: 07/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

Incidental Medical services (IMS) policy was discussed.  Licensee states IMS services are not being provided at this time. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.  When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.  The following information regarding ADA was provided:  US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication:  Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

No deficiencies cited.

An exit interview was conducted with the licensee.  The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. 

LPA provided notice of site visit (LIC9213) and observed it being posted at the facility.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2