<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426208408
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:00:32 PM


Document Has Been Signed on 08/04/2022 04:00 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:KOWALEWSKI FAMILY CHILD CAREFACILITY NUMBER:
426208408
ADMINISTRATOR:SHELLY KOWALEWSKIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 737-9872
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 11DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Shelly KowalewskiTIME COMPLETED:
04:00 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 August 4, 2022 at 12:00 PM Licensing Program Analyst Gigi Reyes conducted an unannounced One (1) Year Required inspection. LPA asked pre- screening questions related to COVID- 19 and licensee’s responses indicate there are no COVID 19 exposures on site. LPA met with licensee, Ms. Shelly Kowalewski and discussed the purpose of the inspection. There were 11 children and 4 staff present.

LPA in the company of Licensee toured the interior and exterior of the day care. LPA observed required licensing forms are posted in the wall at the day care area . LPA observed smoke and carbon monoxide detectors in the FCCH. The regulation fire extinguisher was serviced on 6/26/2022. Home conducts and documents fire and disaster drill every month, last drill was conducted on 7/22/2022
The front yard is enclosed with a 3 foot vinyl fence, however, a visual and physical supervision is required. The play yard has age and size appropriate play equipment. No bodies of water were observed on site. Licensee stated there are no guns or ammunition in the home.

LPA Reyes reviewed facility file, Pediatric CPR and First Aid expires on 1/23/2023. Licensee and Staff renewed the Mandated Reporter Training Certificate which expires on 7/25/2024. LPA reminded Licensee that AB 1207 should be renewed every two year. Licensee and assistant have record or required immunization.

FCCH has current roster of children in care. A sampling of children records were reviewed and found to be current. File contains Emergency and Identification card requirements. Licensee and staff physically check and document the condition of the sleeping infant every 15 minutes

During today's inspection, no deficiency was cited.

Continued on LIC 809 C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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 2


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: KOWALEWSKI FAMILY CHILD CARE
FACILITY NUMBER: 426208408
VISIT DATE: 08/04/2022
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
26
27
28
29
30
31
32
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

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.

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 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
Licensee was reminded that all adults 18 year old 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.

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

Exit interview conducted and report was reviewed with the licensee, Ms. Shelly Kowalewski.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2