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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844377
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:18:09 AM

Document Has Been Signed on 03/23/2023 10:18 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:ROARK FAMILY CHILD CAREFACILITY NUMBER:
334844377
ADMINISTRATOR:ROARK, SAMANTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 243-5456
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 11DATE:
03/23/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Samantha RoarkTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analysts (LPA) Sumayya Habeebulla arrived at the facility on a POC visit to follow-up on pending POC corrections that were due on 11/07/22. LPA Habeebulla had tried contacting Licensee multiple times via email and did not receive the POC’s as of this date.

During the visit LPA cleared the PM 286 deficiency. Licensee provided PM 286 for 6 children enrolled at the facility and stated that she is working on the remaining ones and will be completing them as soon as possible.

Licensee had not created a sleep log for the infants in care. POC is still uncleared.

Licensee also did not have a copy of Flu, MMR and TDAP vaccines for her assistant Kenia Mondragon and the TB test results were also not available for review during the visit.

If a civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.


See LIC 809D for Deficiencies cited during the visit.

An exit interview was conducted with Licensee Samantha Roark. Appeal rights discussed and a copy of this report was provided.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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Document Has Been Signed on 03/23/2023 10:18 AM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 03/23/2023 at 09:55 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: ROARK FAMILY CHILD CARE
FACILITY NUMBER: 334844377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
102425(j)(1)

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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:
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Licensee agrees to create a sleep log for each infant in care and submit the completed log to the department by the POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in having a sleep log for the infants in care which poses potential health, >>>
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>>> safety or personal rights risk to persons in care. This is a repeat violation.
Type B
03/27/2023
Section Cited
HSC1597.622(a)(1)

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(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.
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Licensee agrees to submit proof of MMR, TDAP, Flu Vaccines and TB Test results for her Assistant by the POC due date.
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This requirement is not met as evidenced by:
Based on record review, LIcensee had not obtained the proof of MMR, TDAP and TB test for her Assistant.
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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