515407369-11-18-2019-13-CC-KMAS-BJ326E-20191118160700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 515407369
Report Date: 11/18/2019
Date Signed: 11/18/2019 04:07:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SAMSON, PENNY FAMILY CHILD CARE HOME		FACILITY NUMBER:	515407369
ADMINISTRATOR:	SAMSON, PENNY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 300-2676
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95993
CAPACITY:	14	CENSUS:	DATE:	11/18/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Licensee, Penny Samson		TIME COMPLETED:	04:10 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	An annual/random inspection was made to the facility by Licensing Program Analysts (LPA), Kirk Marks and Sandra Husband. A review of staff records on 11/18/2019 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home. During today’s inspection the home and grounds were toured. Licensee and two qualified assistants were supervising ten children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:00 to 5:30, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the garage, and were made inaccessible by a door knob cover. The home is clean, orderly and comfortable. There are safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 7/2020. One assistant has current pediatric CPR and First Aid certification, which expires on 2/2021 Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. Poisons are locked in an outside shed. The fireplace has been made inaccessible with an approved gate. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. Emergency drill was completed within the last six months, the last drill was on 11/18/2019. Firearms are locked and stored as required separate from the ammunition. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Five children's records were reviewed at 3:30; required emergency information was observed to be on file. The licensee is providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. (continued on page 2)

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Kirk Marks	TELEPHONE: (530) 895-5045
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SAMSON, PENNY FAMILY CHILD CARE HOME	FACILITY NUMBER: 515407369
	VISIT DATE: 11/18/2019

NARRATIVE

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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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Kirk Marks	TELEPHONE: (530) 895-5045
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

LIC809 (FAS) - (06/04)

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