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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153909883
Report Date: 08/09/2021
Date Signed: 08/09/2021 12:19:56 PM

Document Has Been Signed on 08/09/2021 12:19 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:SIMS, SHAINA & JAMILAH FAMILY CHILD CAREFACILITY NUMBER:
153909883
ADMINISTRATOR:SIMS, SHAINA & JAMILAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 548-0072
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 13DATE:
08/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shaina & Jamilah SimsTIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/9/21 Licensing Program Analysts (LPAs) Caroline Harris and Jessika Thompson conducted a case management inspection. The purpose of this report is to cite a violation which was discovered during the inspection.

Upon review of children's files, the licensee's did not have prior Acknowledgement forms for type A violation's, in twelve children's files.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, are being cited on the attached LIC 9099D. An exit interview was conducted with Shaina & Jamilah Sims. A copy of this report and appeal rights were provided. A Notice of Site Visit Form was posted on parent's board and must remain posted for 30 days.
SUPERVISORS NAME: Alice Juarez
LICENSING EVALUATOR NAME: Caroline Harris
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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 08/09/2021 12:19 PM - It Cannot Be Edited


Created By: Caroline Harris On 08/09/2021 at 12:11 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SIMS, SHAINA & JAMILAH FAMILY CHILD CARE
FACILITY NUMBER: 153909883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2021
Section Cited
HSC
1596.8595(c)(1)

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Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services. A licensed child day care facility shall provide to the parents or guardians of
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The licensee's agree to get the signed Acknowledgement (LIC 9224) forms for all children that do not have them in their files, and submit copies to the Fresno CCL office by the due date of 8/16/21.
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each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.
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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:Alice Juarez
LICENSING EVALUATOR NAME:Caroline Harris
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2021


LIC809 (FAS) - (06/04)
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