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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426212147
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:40:13 PM

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: 11DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lisa AdamTIME COMPLETED:
11:50 AM
NARRATIVE
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On 6/23/2021 at 9:45 AM , Licensing Program Analysts (LPAs) Gigi Reyes and conducted an unannounced Required Inspection of Adam Family Child Care Home (FCCH) LPA met with Licensee Lisa Adam and Licensee's assistants and discussed the purpose of the inspection. Due to COVID-19 pandemic, LPA asked the pre screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

LPA toured the interior and exterior of the home. LPAs observed 11 children playing in the backyard. The home uses living room, family room. dining area, one bathroom and fenced backyard for day care.Toxins, detergents, cleaning compounds and medications are stored inaccessible to children. At 10:38 AM, carbon monoxide and smoke detectors were tested and found functional. 2A10 BC fire extinguisher was last serviced on 5/20/2020.

LPA randomly reviewed children's file, file review revealed that Child # 1, Child # 2 and Child # 3 and # 4's immunization are not documented and updated at Child's PM 286 as required by the California Code of Regulations, Title 17, Section 6070. FCCH and Licensee's record were also reviewed. CPR expired 5/19/2019, Mandated Reporter Training per AB 1207 had expired. Licensee was advised that Mandated Reporter Training should be renewed every 2 years.

Continued on 809C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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
VISIT DATE: 06/23/2021
NARRATIVE
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The Licensee is not providing Incidental Medical Services (IMS). Policy was discussed. 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: www.ada.gov/childqanda.htm

LPA reviewed and provided Licensee with the Safe Sleep Regulations and form LIC 9227 Individual Infant Safe Sleeping Plan. LPA reiterated that crib or play yards shall be free from all loose articles, and sleeping infant (0 -24 months) supervision and documentation every 15 minutes. LPAs provided the web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing.

In the areas evaluated, deficiencies were cited under Title 22 Division 12 California Code of Regulations and Health and Safety Code. Appeal Rights were given to Licensee.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2021
Section Cited

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102418(g)(1) Immunizations
(g) The licensee shall document each child's immunizations as required... and shall maintain such documentation for as long as the child is enrolled.
(1) This requirement includes updating each child's PM 286 (6/95)....
This requirment is not met as evidenced by:
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LPA review of record revealed that C1, C2, C3 C4 immunization are not updated on child's PM 286. This poses a potential risk to health and safety of children in care.
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Type B
07/01/2021
Section Cited

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102417(g)(1) Operations of FCCH
(1) Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.
This requirement is not met as evidenced by:
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During the tour LPA observed fire extinguisher was last serviced on 5/20/2020. 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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 3 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: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2021
Section Cited

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b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider... shall complete the mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
This requirement is not met as evidenced by:
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LPA review of Facility File revealed that Licensee's Mandated Reporter Training expired. This poses potential risk to health and safety of children in care.
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Type B
07/14/2021
Section Cited

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102416(c) Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid...
This requirement is not met as evidenced by:
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LPA review of facility file revealed Licensee's CPR expired on 5/19/2019. 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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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