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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566202007
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:43:02 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:NELSON FAMILY CHILD CAREFACILITY NUMBER:
566202007
ADMINISTRATOR:NELSON, KERIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 404-6342
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:14CENSUS: 9DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Keri NelsonTIME COMPLETED:
12:50 PM
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On July 22, 2021 at 11:38 am, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA contacted facility to conducted Covid-19 screening questions prior to entering. LPA met with licensee Keri Nelson and advised the purpose of the inspection. There was nine (9) children in care at the time of the inspection.

The licensee is currently using the day-care room, one bathroom, and backyard for children in care. LPA did not observe any toxin/hazards accessible to children in care. LPA observed a 2A10BC fire extinguisher with a service date of 1/18/21 mounted on the wall readily accessible. Licensee advised to ensure the fire extinguisher is serviced or a new one in purchased every year. The facility has working smoke and carbon monoxide detectors. LPA observed age appropriate toys and furniture readily accessible to children in care. The backyard is fully enclosed. Licensee has an area separated with a fence where they store miscellaneous items inaccessible to children in care. LPA observed age appropriate toys and structures in the backyard readily accessible for children in care. Licensee advised there are no firearms or live ammunition in the home.

809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 566202007
VISIT DATE: 07/22/2021
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LPA observed the facility roster and identified that it was current. A sampling of children records were reviewed and found to be current. LPA verified SB792 Child Care Adult Immunization and Tuberculosis requirements. Currently the licensee does not have liability insurance and had signed waivers in each child's file that was reviewed. Licensee's Pediatric CPR/First-Aid certificate is current and valid until 10/19/2021. Licensee's Mandated Reporter certificate is current and valid until 10/10/2021. The last fire drill was completed on 7/2/2021. LPA discussed current Safe Sleep and Covid-19 requirements with licensee. Licensee is currently following both guidelines.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home 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 (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: http://www.ada.gov/childqanda.htm.

No deficiencies were cited during today's inspection.
THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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