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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543802984
Report Date: 12/21/2021
Date Signed: 12/21/2021 10:42:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:SAMPSON FAMILY CHILD CAREFACILITY NUMBER:
543802984
ADMINISTRATOR:SAMPSON, RUTHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 901-3999
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:14CENSUS: 3DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ruth Diane SampsonTIME COMPLETED:
10:15 AM
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On 12/21/2002, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced annual inspection and met with Licensee, Ruth Sampson. A tour of the home was conducted, and a census was taken. Current facility sketch reviewed, and Licensee confirmed the playroom (bedroom #1), bedroom #2, the hall bathroom and the fenced backyard are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of safety gates and spinner knobs.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A sample of children’s records contained all emergency information specified by regulation.
Business hours are Monday through Friday 7:00 AM to 5:00 PM and other hours as arranged.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations no deficiencies were observed today.

Due to time constraints, this inspection will continue at a later date.

An exit interview was conducted and report was reviewed with the licensee . A copy of the Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Theresa MarquezTELEPHONE: (559) 341-7123
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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