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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627796
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:09:03 PM

Document Has Been Signed on 09/27/2022 01:09 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CARVALHO, SAMANTHA FAMILY CHILD CAREFACILITY NUMBER:
376627796
ADMINISTRATOR:SAMANTHA CARVALHOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 315-8274
CITY:SAN DIEGOSTATE: CAZIP CODE:
92106
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patricia Da SilvaTIME COMPLETED:
01:15 PM
NARRATIVE
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On 09/27/2022 at 10:30 AM, Licensing Program Analyst (LPA), Dana Stevens conducted an unannounced Annual Required Inspection and met with the Licensee's Assistant Patricia Da Silva. LPA disclosed the purpose of the inspection and was granted entry into the facility by the assistant. Assistant informed LPA that Licensee was out of town for a vacation. Five (5) children ages 8 months, 1, 1, 2 and 3, were present in the facility during this inspection. The facility was within ratio and capacity. This facility is a single story, 3 bedroom, 2 bathroom home. The following areas are used for child care: Daycare room, daycare bathroom, and two bedrooms. Off limits areas are Kitchen, Living Room, one bedroom and one bathroom. There areas are made inaccessible through use of safety gates.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. The home has a fenced backyard available for outdoor activities. A detached garage and side yards are off-limits and made inaccessible through the use of latching gates. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Assistant's First Aid and CPR certifications are current and expire on 08.2023. Assistant has required immunization. Assistant is currently exempt from Mandated Reporter Training.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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Document Has Been Signed on 09/27/2022 01:09 PM - It Cannot Be Edited


Created By: Dana Stevens On 09/27/2022 at 12:19 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CARVALHO, SAMANTHA FAMILY CHILD CARE
FACILITY NUMBER: 376627796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not having an Individualized Infant Sleep plan for the infant under 12 months of age which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2022
Plan of Correction
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Licensee will provide proof of completion of Individual Infant Sleep Plan for all Infants up to 12 months of age.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having documented sleep checks for all infants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2022
Plan of Correction
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Licensee will provide documentation of sleep checks for all Infants.
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:Cynthia Gray
LICENSING EVALUATOR NAME:Dana Stevens
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CARVALHO, SAMANTHA FAMILY CHILD CARE
FACILITY NUMBER: 376627796
VISIT DATE: 09/27/2022
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Facility roster is maintained and was reviewed. The last fire and disaster drills were conducted on 02/2022. There is one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards are free from all loose articles and objects. The provider physically checks on sleeping infants every 15 minutes however documentation of the sleep checks was not maintained. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] is maintained for 2 of the infants up to 12 months of age. One Infant's Individual Sleep Plan [LIC 9227] was not available. The provider places infants up to 12 months of age on their backs for sleeping. LPA provided and discussed Safe Sleep Regulations and prohibited items.

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

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

An exit interview was conducted and copy of this report and appeal rights provided. Notice of Site Visit must be posted for 30 days.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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