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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419186
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:02:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CAMPOS FAMILY CHILD CAREFACILITY NUMBER:
197419186
ADMINISTRATOR:CAMPOS, EPELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 772-6186
CITY:SAN PEDROSTATE: CAZIP CODE:
90731
CAPACITY:14CENSUS: 4DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Epelina CamposTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Keyona Scott, conducted an unannounced Annual Required Inspection on 11/16/2021. LPA met with Licensee, Epelina Campos at 11:46 AM. LPA observed four children in care, which includes one infant. All adults present, residing and working in the home are fingerprint cleared and associated to the facility.

LPA toured the inside and outside of the home. The current facility sketch was reviewed. The home is a one bedroom, one bathroom, single-story home with a living room. Licensee confirmed that the living room at the entrance of the home is used as the primary care area. LPA observed play yard crib, books, chairs and other age-appropriate activity items in primary care area. The bedroom at the rear of the home is used on occasion as an alternate napping area. Children in care utilize the bathroom at the rear of the home. There is no fireplace in the home. LPA observed screened heater before the entrance into the kitchen. The kitchen is used for meal and snack time.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Home utilizes ceiling fans as a cooling source and blankets as a heating source. Home has a working telephone. Hazardous materials in the kitchen and bathroom are inaccessible to children. According to the Licensee, there are no weapons or firearms at the home; None were observed by LPA. There is one pet in the home that is made inaccessible to children in care.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197419186
VISIT DATE: 11/16/2021
NARRATIVE
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The home is equipped with a fully charged fire extinguisher which is at least a 2A:10BC. The home is also equipped with at least one working smoke detector. LPA observed inoperable carbon monoxide detector during inspection. There is also a first aid kit equipped in the home. LPA observed Licensee's First Aid and CPR certificate with an expiration date of 09/29/2021; however, Licensee immediately scheduled appointment to renew First Aid and CPR during inspection. Licensee was unable to provide proof of completed Mandated Reporter training. LPA observed required postings posted.

The outdoor play area is located in the backyard, which is fully fenced and free from defects or dangerous conditions. LPA observed an infant play area, ride-along push cars and other age-appropriate play items. No pools, spas, hot tubs, fish ponds or similar bodies of water were observed during the inspection.

LPA observed current Fire Disaster Drill log. Licensee has conducted last fire disaster drill in July 2021.

LPA observed current Child Care Facility Roster of the children enrolled. There are currently four children enrolled at the facility.

Licensee ensures that children in care, are supervised at all times and is aware children shall not be left in parked vehicles. Licensee was informed that car seats are used for transportation purposes only and are not used for sleeping children.

The facility operation hours are Monday through Friday, 7:30 AM to 5:30 PM.


The facility was not operating in substantial compliance during today’s inspection on 11/16/2021. Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies were cited. Please see LIC 809-D of this report for further details.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197419186
VISIT DATE: 11/16/2021
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. 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 if Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: CommonlyAsked Questions about Child Care Centers and the ADA available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA discussed AB633 and informed licensee that, upon receipt of a Type A deficiency, the licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee was advised that each parent or child representative must sign the LIC 9224 Acknowledgement of Receipt of Licensing Report and return by the close of the business day or upon the next day the child returns to the facility or upon a newly enrolled child within the next 12 months and place the LIC 9224 in each child's file.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Epelina Campos.


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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197419186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA did not observe a operable carbon monoxide detector.

Based on observation and interview, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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Licensee states she will purcahse a new battery for inoperable carbon monoxide detector and provide LPA with copy of receipt and text video of operating carbon monoxide detector to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197419186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee was unable to provide Mandated Reporter training certificate. Licensee states last completed over two years ago.

Based on observation, interview, record review the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2021
Plan of Correction
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Licensee states will complete Manadated Reporter training no later than 12/06/2021 and email LPA a copy of the Mandated Reporter training certificate.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 8