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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413659
Report Date: 11/05/2019
Date Signed: 11/05/2019 10:43:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:PENA & CAMPOS FAMILY CHILD CAREFACILITY NUMBER:
197413659
ADMINISTRATOR:PENA CAMPOS, SONIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 942-6971
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:14CENSUS: 6DATE:
11/05/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sonia Pena CamposTIME COMPLETED:
11:00 AM
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 November 5, 2019 at 9:00am, Licensing Program Analysts (LPAs) King and Phillips met with Licensee, Sonia Pena Campos, who guided analyst on a tour of the home for a Random/Annual Inspection. This is a single story 3 bedroom, 2 bathroom home with a Living Room, Kitchen/Dining area, Family Room, Laundry area, and Garage. There is no pool, spa or other bodies of water on the premises.

Present during inspection were Licensee, licensee's spouse, daughter, assistance and 6 children . Days/hours of operation are 7 days a week, less than 24 hours.

Children utilize the Kitchen/Dining area, Family Room and Living Room. Children use Bathroom #1 in the hallway. Off limit areas includes bathroom #2 and all bedrooms (Master bedroom and bedroom #1 and #2) Laundry Room and Garage. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation. Poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children were inaccessible.

Backyard is completely fenced. There is 1 small dog.

Per Licensee, there are no weapons or firearms on the premise. LPAs did not observe any in the home. There are age appropriate toys. Age appropriate napping equipment (mats). The required Fire Extinguisher (2A10BC), Smoke Detector and Carbon Monoxide Detector are in operable condition. Home has central AC and heat. CPR/First Aid expire 07/16/2021. Licensee has required immunization. The First Aid kit was observed and is complete.

LPA's reviewed 3 children files for immunization records and signed Notification of Parents' Rights form.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: PENA & CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197413659
VISIT DATE: 11/05/2019
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
Requirements for fingerprint clearances and associations were discussed with the Licensee. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents.

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation (call within 24 hours and submit the report within 7 days) and on the form LIC624B.

Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If this requirement is not met, civil penalties in the amount of $100 per violation will be assessed.

The following was discussed with the Licensee:

Capacity requirements, Notification of Parent's Rights, Roster requirements (keep updated names and blue sheet), Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee reminded that supervision is required at all times to children in care. Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family child care home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: PENA & CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197413659
VISIT DATE: 11/05/2019
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
Incidental Medical Services (IMS) policy was discussed. No Incidental Medical Services are currently being provided. 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.html

Licensee informed to review Quarterly updates/regulations for 2015-2019 on the department website: Summer 2015 - Incidental Medical Services information.

--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.


--Licensee was informed of responsibility to report suspected Child Abuse, 1-800-827-8724
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Licensee was advised visit www.shotsforschool.org for Immunization information.

The On Duty Worker is available for questions Monday through Friday at (661) 789-6944 from 8:00 AM - 5:00 PM.

No deficiencies cited. A copy of Safe Sleep Proposed Regulations was provided to Licensee. LPAs provided consultation during inspection.

An exit interview was conducted and a copy of this report was read and provided to Licensee Sonia Pena Campos.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3