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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312847
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:19:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SAMAYOA, NATALIAFACILITY NUMBER:
304312847
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
12/03/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee Ms. Samayoa, Natalia TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced In-person Case Management. Licensee initiated inspection for a change in capacity at the existing Family Child Care home. LPA met with Licensee Ms. Samayoa, Natalia present at home, providing care and supervision to One Infant & 1 Toddler present with her. Licensee has been a Child Care provider for a Small Family home since 2015, making her qualified to operate a Large Family Child Care home. LPA observed COVID19, precautions at the facility, with required postings, temperature checks upon arrival, social distancing and activities being held in small groups.

A review of the Facility Personnel Report Summary indicates all adults, residing in the home who require caregiver background check clearances are cleared. There are three adults residing in the home.

Licensee is requesting a Large family childcare home license. Per Licensee, operation hours will be Monday to Saturday, 4:00 AM to 12:00 AM (Midnight) care and supervision shall be provided to children ages Infants to school age children. (3 months -12 years old) Licensee has appropriate bedding for Night care.

A review of the Facility Personnel Report Summary dated (12/3/21) indicates all adults residents, who require caregiver background check clearances exemptions is received and are cleared. Licensee currently have her house hold members assisting her during Day care activities and they have completed the required training including CPR and First Aid training.
Licensee stated currently she is not registered with any Foster Care agency or holds a foster parent license, She was informed if any changes are to occur, Department shall be notified.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central Air /Heating system, the A/C unit is installed in the corner of the side yard inaccessible to children. (Page-1)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SAMAYOA, NATALIA
FACILITY NUMBER: 304312847
VISIT DATE: 12/03/2021
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This is a single story home with three bedrooms/ 2 bathrooms/ living area/ kitchen with dining room/ laundry area/ attached garage / additional day care room in the back / back patio area/ back yard / 2 side yards and front yard.
Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. Per Licensee there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Three Bedrooms, One master bathroom, kitchen, attached Garage are completely off limits. Off limits areas are made inaccessible by means of door knobs. Kitchen is open but all the cabinets have child safety locks installed making the Kitchen area safe. Sharp objects are placed in the locked drawers. Laundry area is adjoining the garage , detergents are placed in a locked cabinet. Licensee has a changing area for Infants and Toddlers in this area , there are no hazardous items placed in this area. Side yards also has a safety wooden gates making the area inaccessible to children. Front yard is only used to enter and exit the home. Licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Designated Child care areas: Children shall enter the home through the main door of the home, they enter into the small passage area leading into the living area, which is used during napping time. There is a fire place in the living area with a safe metal barrier across it. Licensee has designated room for Day care activities in the back yard, where children engage in daily activities . It has age appropriate toys and educational activities. Children's bathroom is located on the left side of the passage area leading to the bedrooms, it was observed to be safe and free of hazardous items. The cabinet under the sink has child safety latches.

OUTDOOR PLAY AREA: The children shall use the back patio and yard for outdoor activities, the yard is completed fenced with concrete and grass flooring. Shade is provided by the roof and natural tree shade. There are age appropriate outdoor toys and activities for enrolled children.

Per Licensee there are no, firearms, pets, weapons or bodies of water on the premises.



Licensee serves Breakfast/ Lunch/ AM / PM snacks and Dinner to children in care. If food is brought from the homes, those containers shall be labeled with child’s name and properly stored or refrigerated. Licensee serves them home cooked meals and have enrolled in the Food Program.(Kid's Care) (Page-2)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SAMAYOA, NATALIA
FACILITY NUMBER: 304312847
VISIT DATE: 12/03/2021
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Older children nap on the cots, linens and blankets are provided by the parents, stored in their individual cubbies and are washed on premises on a weekly basis. Young infants nap in cribs or play pens.

Licensee has completed the required Pediatric First Aid and CPR training which expires 06/23. There are first aid supplies available.

Licensee has a cell phone which is used for childcare, and remains on the premises during hours of operation.



Licensee does provide transportation services to school age children. Appropriate car seats and booster seats are used during transportation.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

The following was discussed with the applicant: ·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.

·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license along with TB test / Immunization and Mandated Reporter training.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
Licensee was also made aware of the Child Advocacy program so he could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.


Fire and safety drills must be performed every six months and documented for review by the Department.
(Page-3)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SAMAYOA, NATALIA
FACILITY NUMBER: 304312847
VISIT DATE: 12/03/2021
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Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.


Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, no infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

Licensee provides Infant care and following was reviewed and new PIN released in September was shared.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to Licensee:

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf



A copy of “A Child Care Providers Guild to Safe Sleep” was provided to Licensee:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SAMAYOA, NATALIA
FACILITY NUMBER: 304312847
VISIT DATE: 12/03/2021
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LPA reviewed with applicant the following safe sleep best practices:

*Always place infants on their backs for sleeping
*Use only a tight-fitting sheet on the crib or play yard mattress
*Do not hang any items from the crib or above the crib
*Keep all items, including blankets, out of the crib or play yard
*Pacifiers may be used as long as they do not have items attached to them
*Infants should not be swaddled or have any items covering them while sleeping
*The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold

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 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

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian. Facility has access to the new system.



OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance with specific instruction where the garage is not permitted for Day care.

The licensee does have a current roster of children in care. Two files were reviewed and meets the requirements.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SAMAYOA, NATALIA
FACILITY NUMBER: 304312847
VISIT DATE: 12/03/2021
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The facility was complying for a (Large Family Child Care Home) with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the Licensee will be notified.

On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

An exit interview conducted with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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