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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543910259
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:24:40 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:CAMPOS, LUPITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 303-1541
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:14CENSUS: 4DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lupita Campos - Licensee TIME COMPLETED:
12:45 PM
NARRATIVE
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On 12/03/21 Licensing Program Analyst (LPA) Jessika Thompson conducted an unannounced Annual Required Inspection. LPA was met by Licensee Lupita Campos. Days and hours of operation are Monday through Friday, when needed, less than 24 consecutive hours per child.

LPA toured the home inside and outside and a census was taken. Licensee’s current facility sketch was reviewed, and Licensee confirmed that the kitchen, dining room, bathroom, and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of spinning door knob covers. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (559) 303-1541.

There are currently no infants in care. LPA discussed Safe Sleep Regulations with licensee. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required; however, three of three children’s files reviewed did not contain proof of completed Affidavit Regarding Liability Insurance forms as required Additionally, Licensee’s Mandated Reporter Training certification is expired Licensee’s pediatric CPR/First Aid is current and expires on 7/24/23 (see next page, LIC809C).

SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as she was unable to provide LPA with proof of current Child Abuse Mandated Reporter training certification. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2021
Plan of Correction
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Licensee indicated she will complete an AB1207 certified Child Abuse Mandated Reporter course. This training can be accessed by logging on to the following website: mandatedreporter.ca. Upon completion, licensee will submit a copy of certification to the Fresno Community Care Licensing Office, by 12/31/21.

Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 children's files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2021
Plan of Correction
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Licensee stated she will ensure all children's files contain completed and signed Affidavit Regarding Liability Insurance (LIC282) forms going forward. A blank LIC282 was provided to the license today. Licensee stated she will send a copy of completed LIC282's for Child #1, Child #2, and Child #3 to the Fresno Community Care Licensing Office by 12/31/21.
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: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
VISIT DATE: 12/03/2021
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A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, LIC809 D)

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Licensee was provided with Appeal Rights.

Exit interview conducted and report was reviewed with Licensee Lupita Campos.

SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4