073408343-6-14-2023-02-CC-JSAI-CSSTZ8-20230614150955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408343
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:10:21 PM

Document Has Been Signed on 06/14/2023 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	SAMUELS, PAMELA		FACILITY NUMBER:	073408343
ADMINISTRATOR:	SAMUELS, PAMELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 302-9044
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee, Pamela, Samuels		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jyoti Saini met with Licensee, Pamela Samuels for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Licensee lives in the house with her mother. Present during this inspection, there are no children in care. The hours of operation are 6:00AM- 6:00PM, Monday -Friday. LPA reminded Licensee to pay annual fee timely to avoid late penalty assessment.
On-limit-areas are: living room, family room, dining area, kitchen, bathroom and backyard.
Off Limit areas are: entire second floor and garage.

LPA observed the following: Daycare Area is clean, orderly, and equipped with age-appropriate toys and equipment for children. Home has a working telephone, a working smoke detector, and a fire extinguisher that meets the minimum requirements. There are no bodies of water in the Daycare area. The fireplace is screened to prevent the access to the children in care. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The outdoor play area is fenced. Licensee stated that she uses nearest Park which is 3 minutes walking distance from the home. Licensee is reminded that 100% visual and physical supervision is required when going to and from the park. Licensee states there are no guns or weapons of any kind in the home. Licensee’s CPR and mandated Reporter training are expired since 2019. Licensee conducted last emergency drill on 06/09/2023 and is properly logged. Licensee provides daily snacks and meals. Discipline policy is redirection. LPA reviewed children’s files. All required postings are properly posted. LPA discussed safe sleep guidelines.

During Inspection, Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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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Document Has Been Signed on 06/14/2023 03:10 PM - It Cannot Be Edited

Created By: Jyoti Saini On 06/14/2023 at 02:15 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SAMUELS, PAMELA	FACILITY NUMBER: 073408343
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Interview, and record review, the licensee did not comply with the section cited above. Licensee does not have valid CPR on the file which poses a potential health, safety or personal rights risk to the children in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Licensee shall enroll herself for the next available CPR/1st Aid training class and submit proof to the department.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Wynn Norona

LICENSING EVALUATOR NAME:

Jyoti Saini

LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SAMUELS, PAMELA	FACILITY NUMBER: 073408343
	VISIT DATE: 06/14/2023

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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.

Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

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/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

TYPE B deficiency was cited during the visit and technical violation's were given.

Exit interview conducted and report was reviewed with the licensee, Pamela Samuels.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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