197494120-11-5-2021-54-CC-ABAY-C8GRXM-20211105132459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494120
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:25:15 PM

Document Has Been Signed on 11/05/2021 01:25 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	SAMPSON FAMILY CHILD CARE		FACILITY NUMBER:	197494120
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	11/05/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robin Sampson-Licensee		TIME COMPLETED:	01:35 PM

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This is an unannounced case management Inspection conducted today by Licensing Program Analyst (LPA) Alicia Bailey for the purpose of inspecting the facility for capacity increase from small family to a large family child care home. LPA Bailey met with Licensee Sampson at 9:30 am on 11/05/2021. During the inspection LPA Bailey discussed, assessed and noted individuals residing in the home. Per Licensee Sampson there are no other license held at this location. This is a single-story home with (3) three bedrooms and (1) one bathroom living room and daycare room. The operating hours would be Monday thru Saturday from 6:00 AM to 4:59 am 23 hours.The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Licensee Sampson owns the property. Licensee’s Sampson provided a copy of the property tax statement was given showing as proof of ownership.

Areas used by the children were inspected as follows: Day-care room, one (1) bathroom, two bedroom, kitchen, living room and front yard and backyard. Licensee Sampson states main care is provided in Day-care room . Licensee stated that children will enter the facility (day-care room) through the backdoor ( the parents & children will come down the driveway to enter thru the back door).

Areas off limits: Master Bedroom

**Rooms that are off-limits need to be made inaccessible during operating hours** The applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

Per the Licensee Sampson there no firearms or weapons in the facility. There are no swimming pool, spa or other bodies of water observed on the premises. LPA Bailey ask Licensee Sampson do you have any pets ? Licensee Sampson stated no.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
	VISIT DATE: 11/05/2021

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Licensee Sampson has completed the Pediatric CPR/First Aid on 08/09/2021 and expires 08/09/2023 on as indicated on the certificates and Preventative Health practices taken on 12/02/2018. The mandated reporter training was completed on 11/07/2020. Licensee completed COVID-19 Self- Assessment on 04/13/2021. Licensee Sampson completed lead component class on 04/11/2021.

At 10:10 AM LPA Bailey ask Licensee Sampson show how the children will enter the facility. Licensee Sampson stated that children will enter the facility (daycare room) through the drive way through the backyard to the backdoor. Licensee Sampson stated she meets the children at the front gate, due to COVID-19 protocol. At 10:20 am LPA Bailey observed posting for COVID-19 protocol, wearing mask and required temperature check wellness station.

Once inside the facility at 10:20 AM LPA Bailey also observed a parent board with the require posting.
At 10:25 AM LPA Bailey viewed the facility sketch to verify which room is mainly used for childcare, Licensee Sampson stated the daycare room. At 10:28 AM LPA Bailey observed children size table and chairs located in the daycare room. LPA Bailey observed large Television mounted to the wall. LPA Bailey ask Licensee Sampson to guided to all the electrical wall socket in the daycare room Licensee Sampson complied. LPA Bailey inspected all electrical wall sockets was child proof and advised Licensee Sampson to check often to ensure that they are covered. Licensee Sampson stated she understood.

Licensee Sampson stated she understood. LPA Bailey also notice individual cubbies for children to store their personal items.

The daycare room will be used for all activities (observed age appropriate toys),eating snack and lunch the children in care will use the kitchen. LPA Bailey asked licensee Sampson what room will the children sleep in? Licensee Sampson stated the children bedroom. LPA Bailey observed napping equipment.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
	VISIT DATE: 11/05/2021

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At 10:34 AM LPA Bailey observed 1 smoke/ carbon monoxide detectors located in the day-care room. LPA Bailey instructed Licensee Sampson to tested carbon monoxide and smoke detectors. Licensee Sampson complied LPA Bailey able to see and hear the smoke detector and carbon monoxide detectors are in operable condition. Licensee Sampson guided LPA Bailey to the infant bedroom , tested the smoke & carbon monoxide detector. LPA Bailey was able to see and hear it was in operable condition. Licensee Sampson guided LPA Bailey to children bedroom and tested the smoke & carbon monoxide detector. LPA Bailey was able to see and hear the smoke detector was in operable condition.

LPA Bailey observed fire extinguisher (2A 10BC) located in the kitchen. Licensee Sampson. At 10:40 am LPA Bailey request to see first Aid kits, Licensee Sampson complied.

At 10:44 AM LPA Bailey request Licensee Sampson to guide on tour of the children’s restroom. The children restroom was inspected, LPA Bailey instructed Licensee Sampson to open cabinet doors. LPA Bailey observed children safety latch. LPA Bailey did not observe any accessible hazards.

After leaving the children bathroom heading back down the hallway at 10:49 AM LPA Bailey reviewed the map of the facility ask Licensee Sampson to guide on tour off limit rooms one (1) bedrooms and living room.

At 10:52 AM LPA Bailey inspected the off-limit rooms and inform Licensee Sampson that the bedroom, need to be lock during childcare hours.

At 10:59 AM LPA Bailey viewed the facility sketch requested to see the living room. At 11:03 AM LPA Bailey was guided down the hallway thru the living room. LPA Bailey observed couch and large television.

At 11:15 AM LPA Bailey inspected the kitchen. LPA Bailey observed child proof latches on kitchen cabinet. LPA Bailey request were the knives are located. Licensee Sampson complied the knives are in an cabinet with child proof lock. LPA Bailey ask Licensee Sampson to do your facility provided meals for the children in care, Licensee Sampson stated yes.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
	VISIT DATE: 11/05/2021

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LPA Bailey and Licensee Sampson toured the backyard at 11:35 AM. LPA Bailey observed the backyard is gated with latch & lock at the top of the 6ft gate. LPA Bailey observed age appropriate toys . LPA Bailey observed three sheds which are use for storage which all had pad locks and off limit to children in care. LPA Bailey requested Licensee Sampson to give her tour of the front yard. LPA Bailey on tour of the front yard. LPA Bailey observed that the entire front yard is enclosed with a fence. Licensee Sampson stated she will walk out to the front gate when the children arrive in the morning and when the parent come to pick the children up in the evening.

LPA Bailey observed the plants was traditional ground coverage plants. LPA Bailey advised Licensee Sampson to always have 100% supervision when children are outside playing. Licensee Sampson stated she understood

At 11:38 AM LPA Bailey reviewed Covid-19 self-Assessment emailed. LPA Bailey reviewed protocols with Licensee Sampson regarding the COVID-19 for family Child Care Home.

At 12:10 PM LPA Bailey reviewed the Disaster Plan, Emergency Disaster Drill ( current drill perform on 11/2/21) were reviewed.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
	VISIT DATE: 11/05/2021

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During the inspection, the LPA Bailey reviewed Forms/Records to Keep in Your Family Child Care Home. LPA reviewed Sudden Infant Death Syndrome (SIDS), Shaken Baby Syndrome, and safe sleep practices with applicant. *Infants should always sleep on their backs, mouths facing up, light bedding.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes 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

The following items must be corrected before capacity increase to license:

1. New first aid kit

LPA Bailey advised Licensee Sampson once licensed, for the large family child care home the applicant is required to adhere to the terms and limitations as stated on the license.

No deficiencies were observed or cited in accordance to Title 22 of the California Code of Regulations and Health & Safety Codes. At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

****Licensee advised that signing the report does not imply agreement with the findings but is acknowledging receipt of the licensing report.*

A copy of this report, a notice of site visit and appeal rights exit interview conducted with the licensee .

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Alicia Bailey
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

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