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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620813
Report Date: 08/07/2019
Date Signed: 08/07/2019 03:51:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GROOM, SAMANTHAFACILITY NUMBER:
393620813
ADMINISTRATOR:GROOM, SAMANTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 986-8611
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:14CENSUS: 6DATE:
08/07/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Samantha Groom TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stacey Williams met with licensee, Samantha Groom for an unannounced random annual inspection. There were six (6) children present during the inspection. All adult residents and staff have criminal record clearances. LPA toured areas of the home accessible to children in care. Off-limit areas include: upstairs, garage, and shed.

LPA observed fire drills are conducted and documented to meet regulation guidelines. LPA reviewed CPR/First Aid certification which expires Mach 2020. LPA reviewed a random sample children’s files and licensee's file. Immunization records were reviewed. LPA toured the home. Licensing posting requirements were posted in the daycare room. Hazardous items and cleaning supplies were inaccessible to children. Medications are inaccessible to children and located on the top shelf in the kitchen cabinet. Licensee stated there are no weapons in the home. Fire extinguisher and smoke detector meet regulation. Carbon monoxide detector was operable. There are no bodies of water on the premises.

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.

Report continues the following page, LIC 809C
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797-
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GROOM, SAMANTHA
FACILITY NUMBER: 393620813
VISIT DATE: 08/07/2019
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LPA discussed the Mandated Reporter Training with licensee. Verification of mandated reporter training was in licensee and her husband’s file. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. In addition, existing licensees must meet requirements by March 30, 2018. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: HTTP://WWW.MANDATEDREPORTERCA.COM

There are no title 22 deficiencies cited for today's inspection.

This facility evaluation report was reviewed and discussed with the licensee. A notice of site visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. The implementation of AB 2370, lead exposure in Family Child Care Homes and proposed safe sleep regulations was discussed. A copy of this report will remain on file for a period of 3 years for public review upon request. Appeal rights were discussed and provided to licensee.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797-
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
LIC809 (FAS) - (06/04)
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