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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426212147
Report Date: 05/20/2019
Date Signed: 05/22/2019 10:53:40 AM

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:ADAM FAMILY CHILD CAREFACILITY NUMBER:
426212147
ADMINISTRATOR:LISA ADAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 354-8281
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 15DATE:
05/20/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Lisa AdamTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection and met with Licensee, Ms. Lisa Adam and Assistant.

When LPA arrived, LPA observed 15 children present, (confidential list). LPA's review of children's files confirmed that ages of the children present range from 4 months to 4 1/2 years old. Licensee had the Assistant 1 dropped off Child 9 to Child 9's parent which reduced the capacity to 14 children. Assistant 2/parent of Child 10 came to assist while Assistant 1 was gone. LPA explained to Licensee, this (reduced capacity) does not correct the deficiency because it does not meet the Health and Safety Code section 1597.465 "At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age."

Based on review of facility personnel report, it was revealed that Assistant, Ms. Shayda Fatoorchi was not associated to the facility. Licensee stated, Ms. Fatoorchi started working in October 2018 and work full time in January 2019. Assistant stated, the transfer request requirements were sent to CCLD a month ago however,it was not verified if the documents were received.

During the inspection, LPA observed a walker in the living room/day care area. Licensee stated a parent brought the baby walker for her/his own child's use. Licensee understood that baby walker is prohibited in a day care facility and immediately removed the equipment from the day care area.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
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: ADAM FAMILY CHILD CARE
FACILITY NUMBER: 426212147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2019
Section Cited
CCR
102417(g)(10)
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A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Section 1596.846(b) and (c).


This requirement is not met as evidenced by:
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Licensee removed the baby walker from the day care area. Licensee agreed to submit a witten plan of correction to CCLD no later than 5/30/2019 on how to ensure all prohibited equipments will not be present in the day care.
gigi.reyes@dss.ca.gov
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Based on LPA's observation, a baby walker was present in the day care area during day care hours. Licensee stated a parent brought the baby walker for his/her own child's use. This poses a potential risk to health and safety of children in care.
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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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
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: ADAM FAMILY CHILD CARE
FACILITY NUMBER: 426212147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2019
Section Cited
CCR
102416.5(d)(2)
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For a Large Family Child Care Home, the maximum number of children... including children under age 10 who reside at licensee's home and the assistant provider's children under age 10, shall be either: More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.
This requirement is not met as evidenced by:
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 Licensee agreed to submit a written plan of correction to CCLD no later than 5/21/2019 to ensure that FCCH stays within ratio and capacity.
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Based on LPA's observation and review of children's files, there were 15 children present ranging from ages 4 months to 4 1/2 years old. Licensee had the assitant #1 dropped off Child # 9 to the parent, another assistant/parent of Child #10 came to assist. LPA explained to licensee this does not correct the deficiency. (Health and Safety Code section 1597.465) This poses an immediate risk to health and safety of children in care.
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Type A
05/21/2019
Section Cited
CCR
102370(d)(2)&(e)
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 102370(j)
This requirement is not met as evidenced by:
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Transfer requirements - LIC 508, LIC 9182 and driver license were emailed to CCLD on 5/20/2019. Licensee agreed to submit a written plan of correction on how to ensure that every inividual who plans to work in her daycare is associated or have a criminal record clearance prior to being employed.
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Based on LPA's review of facility personnel report, the assistant Shayda Fatoorchi is not associated with Adam FCCH. Licensee stated she has been working since October of 2018 and worked fulltime in January 2019. This poses an immediate risk to health and safety of children in care.
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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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
LIC809 (FAS) - (06/04)
Page: 2 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: ADAM FAMILY CHILD CARE
FACILITY NUMBER: 426212147
VISIT DATE: 05/20/2019
NARRATIVE
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During today's Case Management Inspection, deficiencies were cited under Title 22 Division 12 (809 D)

Upon receipt, provide copies of this licensing report to each parent/guardian of enrolled children and to parents/guardians of newly enrolled children during the next 12 months. Acknowledgement of Receipt LIC 9224 form shall be used for this purpose. LIC 9224 after completed shall be maintained in each child's file. (LIC 9224 was provided to the Licensee)

LPAs observed licensee posted the Notice of Site visit.


FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4