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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494120
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:47:11 AM

Document Has Been Signed on 02/04/2022 11:47 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:SAMPSON FAMILY CHILD CAREFACILITY NUMBER:
197494120
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
02/04/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Robin Sampson- LicenseeTIME COMPLETED:
11:56 AM
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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 childcare home. LPA Bailey met with Licensee Sampson at 11:22 am on 02/04/2022. During the inspection LPA Bailey discussed, assessed and noted individuals residing in the home. During today inspection one child was present in the facility.

LPA Bailey observed fire extinguisher (2A 10BC) mounted on the wall in the kitchen. Licensee Sampson provided copies of receipt for annual service to fire extinguisher.

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: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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