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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426212147
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:05:11 PM


Document Has Been Signed on 06/09/2022 03:05 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:ADAM FAMILY CHILD CAREFACILITY NUMBER:
426212147
ADMINISTRATOR:LISA ADAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 354-8281
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 7DATE:
06/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lisa AdamTIME COMPLETED:
03:05 PM
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On 6/9/2022 at 1:50 PM Licensing Program Analyst, (LPA) Gigi Reyes conducted an unannounced Proof of Correction (POC) Inspection at the above Family Child Care Home (FCCH). LPA asked pre-screening questions related to COVID - 19 and based on licensee's responses it was determined that the home was safe and free of any COVID -19 exposure on site. There were 7 children present during the inspection.

On 5/10/2022 Licensee was cited of the following Type B deficiencies:

1. 102417(g)(9)(A)1... (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. During today's inspection, Licensee provided LPA copy of the documented fire and disaster drill which was conducted on 5/11/2022.

2. 1597.622(a)(1) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. During POC inspection, Licensee provided LPA copy of the Licensee's immunization record.

During today's inspection, no deficiency was cited.

Notice of Site Visit was posted.

Exit interview was conducted and report was reviewed with Licensee, Lisa Adams.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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