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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426214792
Report Date: 07/30/2021
Date Signed: 07/30/2021 01:32:33 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:CLARK FAMILY CHILD CAREFACILITY NUMBER:
426214792
ADMINISTRATOR:TAWNIE S. CLARKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 937-2697
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tawnie S. ClarkTIME COMPLETED:
01:30 PM
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On 7/30/2021, Licensing Program Analyst Gigi Reyes conducted an unannounced Required Annual Inspection, LPA met with Licensee Tawnie Clark and discussed the purpose of the inspection. Prior to inspection, LPA asked pre health screening questions related to COVID 19, Licensee's response indicates there are no COVID -19 exposure in the Family Child Care Home (FCCH).

LPA and Licensee toured the interior and exterior of the home, there were 3 children present. Hone is composed of living room, family room, 4 bedrooms and 2 bathrooms. Living room, kitchen, dining area, 1 bathroom and backyard are accessible to children. All 4 bedrooms are not accessible to children in care, doors are are kept locked and have hook on top of the door.

During the tour LPA observed the following, required forms are posted in the prominent location. Appropriate fire extinguisher was last serviced on 1/20/2021. Smoke and carbon monoxide detectors were tested and found functional. Toxins are locked, LPA observed clean, safe and age appropriate toys. There are no bodies of water observed. Licensee stated there are no guns or ammunition in the home.

LPA reviewed the following documents. Staff 1 does not have a TDAP vaccine. Disaster drill is conducted and logged every 2 to 3 months. Last drill was conducted on 7/26/2021.

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: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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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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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 426214792
VISIT DATE: 07/30/2021
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LPA reviewed children records. The records were current, complete and possessed emergency contact information.. Children’s roster is current, children

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

LPAs discussed COVID-19 best practices and guidance. Likewise, LPAs discussed safe sleep regulations with the Licensee. Licensee stated that she does not care for an infants at this time. Licensee was reminded that it is her responsibility to know the regulations for FCCH which can be accessed on-line at www.ccld.ca.gov.

The following deficiency is being cited in accordance to Title 22 of the California Code of Regulations and/or Health & Safety codes. Please refer to LIC 809 D for documentation of deficiencies cited:

Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted with Licensee, Tawnie Clark. A copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of these rights. 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
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC809 (FAS) - (06/04)
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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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 426214792
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/1597
Section Cited

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1597.622 Employees or volunteers at family day care home; immunization...
(a) (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. ....
This requirement is not met as evidenced by:
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LPA review of records revealed that Staff 1 does not have a complete immunization, Staff 1 was missing the TDAP vaccine.
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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: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
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