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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406213712
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:43:01 PM


Document Has Been Signed on 03/02/2022 03:43 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:SIVERLING FAMILY CHILD CAREFACILITY NUMBER:
406213712
ADMINISTRATOR:SARAH MAE SIVERLINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 439-0519
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:14CENSUS: 12DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Sarah Mae SiverlingTIME COMPLETED:
11:42 AM
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On 3/2/22, at 9:15 AM Licensing Program Analysts (LPA) Francisca Velazquez conducted an unannounced Required inspection of the Family Child Care Home (FCCH). Prior to entering the facility, LPAs conducted COVID-19 questionnaire and based on Licensee's responses it was determined the home is safe and free of any COVID-19 exposures. LPAs met with Sarah Mae Siverling, Licensee of the FCCH and Russel Siverling, Spouse and assistant of the FCCH and explained the nature and purpose of the inspection. LPAs notes twelve (12) children are on site during this inspection.

LPA, in the company of the Licensee, toured the exterior and interior of the FCCH. This is a two-story home. The first floor of the home, which consists of playroom, dining area, living room, bathroom in the hallway and kitchen are accessible to children in care. The second story of the home is excluded from services. LPA notes a child safety gate is at the base of the stairwell preventing the children's access to the FCCH's upper story.

The FCCH is clean, orderly and has ventilation to afford for the children’s comfort and safety. Medication and sharps in the FCCH are stored in the kitchen in elevated cabinets and are inaccessible to children. The home's cleaning compounds are stored under the sink with a safety latch, more cleaning items are also stored in an elevated cabinet in the home’s hallway and in an elevated shelf in the laundry room all areas are inaccessible to children in care. Toys, furniture and equipment observed in the FCCH are age appropriate.

Required forms are posted on the FCCH living room wall by the hallway. The FCCH's living room has a fireplace which is inaccessible to children. Licensee also stated that the fireplace is not used at all. The FCCH has smoke and carbon monoxide detectors which were tested at 9:38 AM and found to be operable. The FCCH has a regulation fire extinguisher which was serviced on 9/16/2021. LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually. LPA reviewed the home’s fire/disaster drill documentation. The last drill was completed on 2/2/22. CONT 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIVERLING FAMILY CHILD CARE
FACILITY NUMBER: 406213712
VISIT DATE: 03/02/2022
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The backyard is enclosed by a wooden fence. Toys and play equipment are also age appropriate and in satisfactory condition. The backyard has plenty of trees to provide shade to children in care. Licensee has also added shade by means of canopy. LPA observed bodies of water on site by means of a jacuzzi. LPA observed that jacuzzi to be completely locked and also observed that the jacuzzi did not have any water inside. Jacuzzi is located in an area that is fenced and off-limits to children. Licensee stated that children only pass by the locked Jacuzzi to get to the backyard and children are always accompanied by adults.

A sampling of the children's records was reviewed. The records are current, complete and possessed emergency contact information. The Licensee's records were also reviewed. Licensee and Spouse have Pediatric CPR and First (EMSA approved) expiring 2/9/2023 and Mandated Reporter certificates expire on 12/28/20. Licensee was not aware that Mandated Reporter certificate needs to be renewed every two years. Licensee and Spouse agree to renew their Mandated Reporter certificate every two years moving forward.

The Licensee notes firearms are stored on site. LPA observed that firearms are located in the second floor of the home which is not accessible to children in care. Firearms are locked in a large safe in the Licensee’s bedroom. Safe required a numerical code to unlock. Licensee and Spouse are the only adults that have the numerical code. Licensee stated there is no ammunition stored in the home.

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

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.

CONT 809-C

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIVERLING FAMILY CHILD CARE
FACILITY NUMBER: 406213712
VISIT DATE: 03/02/2022
NARRATIVE
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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 [facility representative] 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.

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

Exit interview conducted and report was reviewed with the licensee Sarah Mae Siverling.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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