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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017036
Report Date: 06/12/2025
Date Signed: 06/12/2025 02:48:57 PM

Document Has Been Signed on 06/12/2025 02:48 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:AMADOR FAMILY CHILD CAREFACILITY NUMBER:
198017036
ADMINISTRATOR/
DIRECTOR:		AMADOR, SYLVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 638-7278
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
06/12/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sylvia Amador, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced annual/random inspection to the above facility on 06/12/25. LPA arrived at the facility at 11:00 AM and met with Sylvia Amador, Licensee who guided analyst on a tour of the facility. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee. Per licensee, Sylvia Amador facility hours are Monday to Friday from 8:30 a.m. to 6:00 p.m. Per licensee, she provides care to children 0-13 years old.

This is a one story home located on the first level. The home consists of 3 bedrooms, 2 & 1/2 bathrooms, kitchen, dining room, living room, den (children's play room), laundry room, garage, side yard, front yard and backyard (fenced). Per licensee, parents enter the home through the main entrance which leads to the living room.

The children use the half bathroom in the back room, dining room, living room, den, and backyard (fenced). Per licensee, areas off limits to children and parents include: 2 bedrooms, 2 bathrooms, kitchen, laundry room, front yard, detached garage, side yard, and the very back of the backyard. LPA did not observe stairs in the home. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 11:10 a.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with the living room, LPA observed sofas, a coffee table, and TV in the living room. There is a fireplace in the living room which has been blocked off to prevent access. Next LPA toured the dining room and observed a dining table and chairs in the dining room. Next LPA toured the kitchen and observed child proof safety latches on the cabinet under the sink where licensee stores cleaning compounds.
REPORT CONTINUES ON NEXT PAGE 1 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036
VISIT DATE: 06/12/2025
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LPA observed accessible knives in the kitchen drawer and was not locked. Per licensee, currently she only has two 20 months old infants who can not reach the drawer and they do not go to the kitchen. Next LPA toured the den (children play room) and observed children tables, chairs, and toys in the daycare room. During this inspection LPA observed two infants (20 months old) and licensee's biological child were playing the den. Next LPA toured the half bathroom in the back bedroom and did not observe any hazards. Per licensee children only walk through the last bedroom to use the bathroom. Per licensee, the required 2A 10BC fire extinguisher was purchased sometimes October 2024, but licensee was not able to locate the receipt. Licensee tested the carbon monoxide and smoke detectors in the living room it did not work, licensee, attempted to change the battery still did not work. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

Next LPA toured the backyard fenced. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys, slide, swings and other materials for children to play with. LPA observed a 7.5 feet high, big trampoline in the backyard that licensee stated daycare kids play on the trampoline. LPA observed dog poops in the backyard, on the dirt area, in the children outdoor playarea. Pictures were taken. Back of backyard which is off-limit area, is gated to prevent access. Per licensee, side yard is also inaccessible to the children. The licensee states that supervision is always provided.

Per licensee, she provides food for children in care. Licensee was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated. Per Licensee, at 12:10 p.m there are weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises. Per licensee, there is one dog on the premises which are accessible to the children.

The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. During this inspection three children were present in the home with licensee. All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, currently she does not have assistant. 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.
REPORT CONTINUES ON NEXT PAGE 2 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036
VISIT DATE: 06/12/2025
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The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 09/2025. Licensee completed required mandated reporter training on 09/22/23. There are first aid supplies available on the premises in the closet in the hallway of bedrooms. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.

At 12:10 p.m., facility roster was reviewed and completed. Per licensee currently there are 4 children enrolled, one being licensee's biological child. LPA reviewed 2 children's records, including emergency information from 2 enrolled children, and all 2 reviewed files were completed. Per licensee, she does not provide transportation.

The licensee has proof of immunization against influenza and pertussis. Licensee did not have proof of immunization for measles. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Per licensee, she has not conduct fire drill for a long time.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall in the daycare area. LPA observed a 7.5 feet, big trampoline in the backyard in the children daycare area and per licensee children play on the trampoline.

Currently licensee has outstanding balance of $980. LPA mailed certified letters regarding her license outstanding balance on 08/28/23 and 01/24/24, and LPA has not heard back from licensee.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is telephone service via a a cellphone that is used and the cellphone stays at the facility during operation hours. Per licensee she does not carry liability insurance or a bond in accordance with standard
established by Family Child Care statue. Signed statements (LIC282) on 2 reviewed file.

INFANT CARE: Per licensee, currently she has two (20 months old) infants enrolled in her daycare. Per licensee, infants sleep in the living room where they are under supervision. LPA informed licensee Infants shall be checked on every 15 minutes and the time of each 15- minute check shall be documented with child’s name and date. Licensee did not have nap chart for two current infants. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. LPA observed LIC 9227 on two infants files. A copy of the LIC 9227 was provided to Licensee.
REPORT CONTINUES ON NEXT PAGE 3 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036
VISIT DATE: 06/12/2025
NARRATIVE
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SAFE SLEEP: LPA discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/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 http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Boppy recall: https://www.cpsc.gov/Recalls/2021/The-Boppy-Company-Recalls-Over-3-Million-Original-Newborn-Loungers-Boppy-Preferred-Newborn-Loungers-and-Pottery-Barn-Kids-Boppy-Newborn-Loungers-After-8-Infant-Deaths-Suffocation-Risk

Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

LPA Eivazian informed licensee, Sylvia Amador that this report dated 06/12/2025 document(s) 3 Type A citations. Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

REPORT CONTINUES ON NEXT PAGE 4 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 11
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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036
VISIT DATE: 06/12/2025
NARRATIVE
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Also, LPA Eivazian informed the licensee, Sylvia Amador to provide a copy of this licensing report dated 06/12/25 that documents any 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.

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.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Licensee, Sylvia Amador was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.



During the exit interview, the Licensee, Sylvia Amador confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee, Sylvia Amador.

REPORT END 5 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 06/12/2025 02:48 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 06/12/2025 at 12:32 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation from backyard (day-care outdoor play area), the licensee did not comply with the section cited above and LPA observed dog poops on the dirt area accessible to the children (Pictures were taken) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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4
Per licensee, during this inspection licensee cleaned up the back yard and cleaned dog poops from backyard outdoor playarea.
Type A
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observation the licensee did not comply with the section cited above and LPA observed 7.5 feet high big trampoline in the backyard, daycare area, per licensee children play on the trampoline which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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4
Per licensee, she will move the trampoline to the off-limit area effective tomorrow for her biological children use only.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 06/12/2025 02:48 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 06/12/2025 at 12:32 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA's observation, the licensee did not comply with the section cited above and licensee did not have child safety latch on the kitchen drawer where she stores knives which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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During this inspection licensee added a child safety latch on the kitchen drawer where she stores knives to make it inaccessible to the children.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee statement, the licensee did not comply with the section cited above and did not conduct fire drill for a long time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Per licensee she will conduct a fire drill with children and will document the time and date on the fire drill log.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 06/12/2025 02:48 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 06/12/2025 at 12:32 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee statement, the licensee did not comply with the section cited above and while infants nap she sits next to them but she did not document her supervision every 15 minutes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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2
3
4
Per licensee, she will check on napping infants every 15 minutes to ensure they are breathing and will document the time and date on the napping chart.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on licensee file review, the licensee did not comply with the section cited above and licensee did not have proof of immunization against measles on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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2
3
4
Per licensee, she will have proof of immunization against measles on file by 06/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 06/12/2025 02:48 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 06/12/2025 at 12:49 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102384(a)
102384 Licensing Fees
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code Section 1596.803:


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on facility file review, the licensee did not comply with the section cited above and licensee has $980 outstanding balance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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2
3
4
Per licensee, she will pay her outstanding balance by 06/27/25. LPA provided licensee with her online payment Pin number.
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.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 06/12/2025 02:48 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 06/12/2025 at 12:53 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: AMADOR FAMILY CHILD CARE
FACILITY NUMBER: 198017036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 LPA's observation the licensee did not comply with the section cited above, licensee tested the smoke and carbon monoxide detector in the living room, it did not work, licensee attempted to change the battery still did not work which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
1
2
3
4
Per licensee, she will have an operable smoke and carbon monoxide detector in the facility by 06/13/25.
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.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 11 of 11