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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910259
Report Date: 12/18/2019
Date Signed: 12/18/2019 02:03:45 PM

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:CAMPOS, LUPITA FAMILY CHILD CAREFACILITY NUMBER:
543910259
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
12/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lupita Campos - Licensee TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessika Thompson conducted an unannounced annual/random inspection. LPA met with Licensee Lupita Campos who provided a tour of the home, as shown on the facility sketch. Licensee, her husband, and infant child live in the home. There are no firearms or “bodies of water” on the premises. Accessible areas of the home are the living room, dining room, kitchen, hall bathroom and bedroom #1. Off limits areas are made inaccessible by use of spinning door knob covers which were observed by LPA today. Required forms are posted. Smoke and carbon monoxide detectors meet State Fire Marshall standards. The home is kept clean and orderly, with heating and ventilation for safety and comfort. Safe toys and play equipment were observed. There is a working telephone. Adequate supervision was provided during this visit. Outdoor play areas are fenced and supervised by the licensee or care giver. Capacity as specified on the license is being maintained. Staff-child ratios are maintained. Children’s records contain all emergency information specified by regulation. There are no excluded individuals present at this home. All adults who reside or work in the home have a criminal record clearance or exemption as indicated on the Facility Roster. Licensee has current pediatric CPR and First Aid that expires on 08/15/21. Licensee has proof of Child Abuse Mandated Reporter training, completed 03/03/18. Licensee was advised that this training must be completed every two years. Safe sleep concepts for infants in care was discussed and corresponding handouts were provided to the Licensee. Lead safety was discussed, and LPA provided Licensee with a brochure. Licensee understands that lead safety information must also be provided to parents and/or authorized representatives of children in care. Provider Information Notices were discussed, and licensee is aware that forms and updated information may be obtained on the Department’s website: (www.ccld.ca.gov). Incidental Medical Services (IMS) policy was discussed. Licensee reported that currently she does not have any children enrolled requiring IMS. Licensee was advised that if/when any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Business hours are Monday-Friday, 5:00 AM to 6:00 PM, and as arranged.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found (see next page):
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: CAMPOS, LUPITA FAMILY CHILD CARE
FACILITY NUMBER: 543910259
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/01/2020
Section Cited

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 Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement was not met as evidenced by records review. Today, upon review, LPA found that the last fire & disaster drill conducted occurred over one year ago. This poses a potential risk to the health, safety, or personal rights of children in care.
Type B
01/01/2020
Section Cited

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 Immunizations. Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
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This requirement was not met, as evidenced by records review. During today's inspection, the licensee was unable to provide an immunization record for Child #1. This poses a potential health, safety, or personal rights risk to 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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2019
LIC809 (FAS) - (06/04)
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