393620813-9-6-2023-53-CC-ESIA-CVEVJZ-20230906162933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393620813
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:29:39 PM

Document Has Been Signed on 09/06/2023 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GROOM, SAMANTHA		FACILITY NUMBER:	393620813
ADMINISTRATOR:	GROOM, SAMANTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 986-8611
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	14	CENSUS: 6	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Samantha Groom		TIME COMPLETED:	04:45 PM

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 09/06/23, Licensing Program Analyst (LPA) Elvira Sierra, conducted an unannounced Annual visit and met wit Licensee, Samantha Groom. Form (LIC 126), Entrance Checklist for Family Child Care Homes, was provided to Licensee. Licensee owns the home. Home is two story 4 bedroom and 2 1/2 bathroom house. Facility hours of operation are Monday-Friday from 06:00am to 06:00pm. Present in the facility was Licensee caring for five day-care children. Licensee's minor son was also present during the inspection. A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Right. Off-limit areas are: Entire upstairs, right side of the backyard, storage shed in the backyard and the garage. Off-limits areas will remain inaccessible to children by closed doors, and/or supervision. The licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa and any new construction to the home. Hazardous items/cleaning supplies and knives are stored inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 2-A-10-BC fire extinguisher. Licensee stated there are no weapons in the home. There is a fireplace in the living room area that is properly barricaded. Outdoor play space is fully fenced and is free of any dangerous conditions. The swing and play structure in the backyard is secured to the ground and in good repair. There are no bodies of water on the premises. Licensee stated she provide meals to the children and she is register with Child Care Food Program with Resource and Referral. Fire drills was conducted is conducted at least once every six months and is properly documented. Preventative health and current pediatric CPR and first aid training was verified, and CPR expires 08/05/2024. Mandated Reporter Training expires on 12/21/23. Report continues on subsequent page 809C---

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GROOM, SAMANTHA	FACILITY NUMBER: 393620813
	VISIT DATE: 09/06/2023

NARRATIVE

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All individuals subject to criminal background review have obtained a criminal record clearance. 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.

Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department if provided. 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. Licensee states she will not administer medication. 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.

Licensee was made aware of the (LIC9227) Individual Infant Sleeping Plan, for infants under 12 months and sleep logs for all infants in care under 24 months need to be maintained in children’s files. LPA discussed and provided an example of a sleep log and the safe sleep regulations with Licensee and provided 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.

Report continued on subsequent 809C...

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GROOM, SAMANTHA	FACILITY NUMBER: 393620813
	VISIT DATE: 09/06/2023

NARRATIVE

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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 encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

An exit interview was conducted. This report and Appeal of Rights were reviewed and provided to Licensee, Samantha Groom.. Notice of Site Visit posted and should remain posted for 30 days.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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