197494120-5-5-2023-54-CC-RNAO-CRJP8W-20230505110612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494120
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:06:25 AM

Document Has Been Signed on 05/05/2023 11:06 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 CARE		FACILITY NUMBER:	197494120
ADMINISTRATOR:	SAMPSON, ROBIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 986-5056
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90061
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 2	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Robin Sampson		TIME COMPLETED:	11:26 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced annual required inspection at the above facility on 05/05/2023 at 9:20am. LPA met with Licensee Robin Sampson who guided analyst on a tour of the facility. There were two children present when LPA arrived. Facility capacity is in compliance for Large Family Child Care Home. Hours of operation are Mon-Sat, 24 hours of the day. Licensee understands that they cannot care for any child over 23 hours a day. This is a one story home which consists of three bedrooms and one bathroom. Areas used by the children include the Day Care room, two bedrooms, bathroom, living room, front yard, and backyard. Areas off limits to children include the kitchen/dining area, and one bedroom. The bathroom that children use was observed to be clean and free of hazards. Food is provided by Licensee. Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated. Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA reviewed required posted documentation for Facility License and Publication (PUB) 394- Notification of Parent Rights. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on May 2023. Smoke detector was tested and are operable. At 9:43am, LPA did not observe a carbon monoxide detector in the home. Fire extinguisher indicated fully charged and was serviced within the year. The home maintains telephone service via cell phone. The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. Open face heater is screened to prevent access by children.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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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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: 05/05/2023

NARRATIVE

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LPA observed that detergents, cleaning compounds and medication are inaccessible to children. Licensee understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home. At this time, the Licensee does not have any infants in care. Licensee does not have any children that require over night care.

Currently, children are using the backyard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC 508- Criminal Record Statement, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
	VISIT DATE: 05/05/2023

NARRATIVE

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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.

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

The deficiency listed on the following page was observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the children’s health & safety.

Exit interview conducted and report was reviewed with Licensee, Robin Sampson. A notice of site visit was given and must remain posted for 30 days.

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/process.

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2023 11:06 AM - It Cannot Be Edited

Created By: Raul Navarro On 05/05/2023 at 10:38 AM

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

FACILITY NAME: SAMPSON FAMILY CHILD CARE	FACILITY NUMBER: 197494120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.543

Licensure Requirements

Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The Licensee did not have a carbon monoxide detector in the home during the inspection.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	Licensee will purchase a carbon monoxide detector and submit proof of purchase to LPA by the POC date of 05/26/23.

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:

Karen Chambers

LICENSING EVALUATOR NAME:

Raul Navarro

LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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