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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846580
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:10:40 PM

Document Has Been Signed on 05/29/2024 02:10 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CAMPOS FAMILY CHILD CAREFACILITY NUMBER:
364846580
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
05/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Deanna Campos TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On date and time listed, Licensing Program Analyst (LPA) Aman Lama arrived at the facility to conduct a pre-licensing inspection. Present during this inspection was Applicant, Deanna Campos. LPA toured the facility, inside and out and the following was observed and/or discussed:

Normal days and hours of operation: Monday-Friday 6:00am-6:00pm.
OFF-LIMIT AREAS INCLUDE: Entire 2nd floor, garage, and the side yards in the outdoor area.
· There was a smoke detector and carbon monoxide present as well as a fire extinguisher.
· There are weapons in the home at this time, which meet Title 22 Regulation requirements.
· Verification of control of property is on file.
· Mandated Reporter Training was completed on: 02-25-24 and expires 02-26
· Pediatric CPR and First Aid Card was completed on: 02-24-24 and expires 02-26
· Health & Safety Certificate was completed on: 03-03-24

·There is no pool on the property at this time. Applicant understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced off per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.


· There is a fruit plant in the backyard, which has thorns-SEE corrections on page 3.
· The Applicant was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 364846580
VISIT DATE: 05/29/2024
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The following was discussed with the applicant(s):
- LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Applicant understands responsibilities of being a mandated reporter
- Applicant understands the importance of the knowledge of regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited
-LPA also informed Applicant of the importance of checking for recalled infant devices. LPA recommended they register any and all infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ to be notified of any recalls on their purchased equipment.

-Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

- Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.



- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 364846580
VISIT DATE: 05/29/2024
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- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200

Applicant, Deanna Campos confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

The following corrections are requested before the application for a Small Family Child Care Home (FCCH) can be submitted for approval with a maximum capacity of 6, or 8 with parent notification.

1. The plant in the backyard in the left corner contains thorns, which needs to be made inaccessible to children in care.

2. The right side yard has a small fence, but not very sturdy. There are tools accessible, which need to be made inaccessible before getting licensed.

3. The propane tank for the barbecue needs to be detached from the barbecue and made inaccessible.


Exit interview was conducted and report was reviewed with the Applicant, Deanna Campos.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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