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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610566
Report Date: 04/04/2023
Date Signed: 04/05/2023 05:35:35 AM

Document Has Been Signed on 04/05/2023 05:35 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CAMPISTA, JOSEFA FAMILY CHILD CAREFACILITY NUMBER:
136610566
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
04/04/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Josefa CampistaTIME COMPLETED:
02:46 PM
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On 4/4/23 at 11:45p.m., Licensing Program Analyst (LPA), Cindy Meier conducted an unannounced Case Management-licensee initiated inspection with licensee, Josefa Campista. LPA Meier informed licensee that the purpose of the inspection was for the requested change of capacity. Licensee led LPA on a tour of the facility. There were seven (7) children present, two (2) infants, four (4) preschoolers, one (1) school age and one (1) staff member at the facility during the time of the inspection. Hours of operation are Monday through Sunday 5:00am – 12:00midnight. LPA used Language Link during the inspection which provided translation for the licensee.

On 3/6/23 a fire clearance was granted for fourteen (14) children. Licensee will use the following areas for childcare: dining room, playroom, bedroom #2, bathroom #1, and backyard. Off Limit areas include: living room, bedroom #2, bedroom #3, bathroom #2, and kitchen Off limit areas are inaccessible to children by use of safety gates, safety latches or doorknob covers. Licensee utilizes the fenced back yard for outdoor activities. LPA informed licensee to ensure children are supervised at all times during outdoor activities. Licensee stated there are no bodies of water and LPA did not observe any bodies of water during the inspection.
There are sufficient age appropriate toys, games, and play equipment available. The home was clean and orderly during inspection. Detergents, cleaning compounds, and medicines are inaccessible to children in care and poisons are to be locked away. The fire extinguisher is rated 3A:40B:C and located in the kitchen, smoke alarm and carbon monoxide detectors meet requirements and are operational. There is a working phone in the home. Licensee stated there are no firearms, other weapons or ammunition on the property.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566
VISIT DATE: 04/04/2023
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Licensee maintains documentation of proof of control of property for review by the Department. Property Owner/Landlord Consent form LIC9149 is on file, signed by landlord and approves licensee to care for fourteen (14) children. Licensee’s Mandated Reporter AB1207 training will expire 8/2023. Licensee will send LPA certificate of completion. Pediatric CPR and First Aid certifications expire on 2/24/2025. Immunization records per SB792 were reviewed and met regulations. Required documents are posted.

All adults living or working in the home have been fingerprint cleared and associated. Facility roster was available and updated. Children’s files were reviewed and found incomplete. The last fire and disaster drill were conducted and documented on 03/2023.

There are no cribs or play yards available for each infant who is unable to climb out of the crib or play yard. LPA observed infant sleeping in a bouncy seat in a room with the door closed. The provider does not physically check on sleeping infants every 15 minutes and document their sleep. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] is not maintained for each infant up to 12 months of age.

LPA reviewed the following with licensee: SIDS, car seat law, reporting requirements, shaken baby syndrome, care and supervision, and COVID-19 precautions/guidelines. Licensee was also reminded the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care.

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.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
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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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566
VISIT DATE: 04/04/2023
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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.

Incidental Medical Services (IMS) policy was discussed. 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

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. San Diego Regional Office Duty Line was provided: (619) 767-2248.

The maximum capacity for a Large Family Child Care home: 12 children (with a qualified assistant) with no more than 4 infants; or (with landlord consent) 14 children (with a qualified assistant) with no more than 3 infants, 1 child enrolled in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. When there is no qualified assistant, 14 years of age or present, the capacity reverts to the requirements for a Small Family Child Care.

Per California Code of Regulations, (Title 22, division 12 & Chapter 3) one (1) Type A citation, and three (3) Type B citations are being cited on the attached LIC 809-D.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
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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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566
VISIT DATE: 04/04/2023
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LPA Cindy Meier informed Licensee, Josefa Campista that this report dated 4/4/23 document(s) one (1) Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Cindy Meier informed the Licensee, Josefa Campista to provide a copy of this licensing report dated 4/4/23 that documents Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Increase in capacity was not approved until the following deficiencies are corrected:
-LIC9227 form filled out in Child’s files
-Sleep for infants documented every 15 minutes
-Children’s files complete
-Purchase a crib or play yard for every infant enrolled

Exit interview conducted and report was reviewed with licensee, Josefa Campista. A copy of this report, along with Appeal Rights (LIC9058), were provided. A notice of site visit was given and must remain posted for 30 days. LPA observed that the notice of site visit was posted during the inspection. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/05/2023 05:35 AM - It Cannot Be Edited


Created By: Cindy Meier On 04/04/2023 at 01:12 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2023
Section Cited
CCR
102425(a)

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102425(a)
There shall be one crib or play yard for every infant who is unable to climb out of the crib or play yard.



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Licensee was unaware that bouncy seats were prohibited in Family Child Care homes and did not have any cribs or play yards for infants to sleep in. Licensee will review the Safe Sleep regulations and submit a
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Based on observation and interviews conducted, the licensee did not comply with the section cited above in that one (1) infant was allowed to sleep in a bouncy seat, which posed an immediate health, safety or personal rights risk to child in care.

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declaration and summary to CCLD by 4/14/2023 stating her acknowledgement of the information reviewed and the plan of operation to remain in compliance regarding Safe Sleep. Licensee will provide a crib or play yard for each infant by 4/7/23.

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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:Jason Garay
LICENSING EVALUATOR NAME:Cindy Meier
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2023 05:35 AM - It Cannot Be Edited


Created By: Cindy Meier On 04/04/2023 at 01:26 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
102425(c)

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102425(c)
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
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LPA provided Licensee with a blank LIC 9227 form and PIN 20-24-CCP "Safe Sleep Regulations". The Licensee stated she will submit a copy of the completed LIC 9227 for the infants in care for the plan of correction to the San Diego Regional Office by 4/14/2023.
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Based on record review, the Co-Licensee did not comply with the section cited above in not having the required LIC 9227 Individual Sleeping Plan for infant in care which poses a potential health, safety to persons in care.
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Type B
04/04/2023
Section Cited
CCR102425(J)(1)

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102425 (J)(1)
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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Licensee was provided with a sample Safe Sleep log and stated she will begin documenting infants sleeping status every 15 minutes. The Licensee will send a copy of the completed log for the dates of 4/2/23 - 4/7/23 to CCLD by 4/12/23.
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Based on analyst interview and record review, the licensee did not comply with the section cited above as she is not documenting the infant she has in care's sleeping status every 15 minutes as required by regulation which poses/posed a potential health, safety or personal rights risk to the child 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:Jason Garay
LICENSING EVALUATOR NAME:Cindy Meier
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2023 05:35 AM - It Cannot Be Edited


Created By: Cindy Meier On 04/04/2023 at 01:34 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPISTA, JOSEFA FAMILY CHILD CARE
FACILITY NUMBER: 136610566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
102417(g)(7)

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102417 (g)(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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LPA provided Licensee the LIC311D which lists required forms for children's files. Licensee stated she will provide the three children's completed files to CCLD by 4/21/23.
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Based on record review, the licensee did not comply with the section cited above in (4) out of (7) children did not have completed forms for review which poses a potential health, safety or personal rights risk to persons 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:Jason Garay
LICENSING EVALUATOR NAME:Cindy Meier
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


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