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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376618438
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:35:31 PM

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:SMITH, MICHELE FAMILY CHILD CAREFACILITY NUMBER:
376618438
ADMINISTRATOR:MICHELE SMITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 565-2867
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:14CENSUS: 3DATE:
11/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Michele SmithTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennifer Lott and Daniel Pena conducted an unannounced case management visit to cite unrelated deficiencies noted during a visit from 11/18/2021. During the 11/18/2021 site visit, it was determined that 1:5 occupants who live in the home did not receive a criminal background clearance.

A deficiency is being cited per Title 22 regulations and noted on the attached LIC 809D. In addition, Civil Penalties are being assessed for no criminal background clearance on the attached LIC 421BG in the amount of $500.00. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
An exit interview was conducted with Licensee, Smith and a copy of this report along with the Appeal and Licensee's Rights (LIC 9058, 01/16) were provided. Signature on this form below, confirms receipt. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Jennifer LottTELEPHONE: 619-782-8300
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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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: SMITH, MICHELE FAMILY CHILD CARE
FACILITY NUMBER: 376618438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2021
Section Cited

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Criminal Record Clearance - (a) Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. This requirement is not met as evidenced by:
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Based on LPA's observations, interviews and record review, 1:5 adults who reside in the home did not have a criminal record clearance. This poses an immediate health & safety risk to residents in care. A civil penalty is being assessed in the amount of $500 and noted on the attached LIC 421BC.
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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: Tashima DanielTELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Jennifer LottTELEPHONE: 619-782-8300
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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