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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629029
Report Date: 09/06/2022
Date Signed: 09/07/2022 08:48:43 AM

Document Has Been Signed on 09/07/2022 08:48 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SIMON, IMMACULA & RICHARD FAMILY CHILD CAREFACILITY NUMBER:
376629029
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/06/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Richard SimonTIME COMPLETED:
10:39 AM
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On 09/06/22 at 9:30am, Licensing Program Analyst (LPA), Cindy Meier conducted an unannounced Case Management-licensee initiated inspection with Co-Licensees, Richard and Immacula Simon. LPA Meier informed Co-Licensees that the purpose of the inspection was for the requested change of capacity. Co-Licensee led LPA on a tour of this three (3) bedroom, 2 bath home. There were no children present at the facility during the time of the inspection. Hours of operation are Monday through Saturday 6:00am – 10:00pm and Sundays 6:00am – 6:00pm.

On 07/28/2022 a fire clearance was granted for fourteen (14) children. Fire clearance states Room 3 is not to be used for children. Co-Licensee will use the following areas for childcare: living room, dining room, bedrooms #1 and bathroom #2, front yard and backyard. Off Limit areas include: kitchen, bedrooms #2, #4, room #3 and bathroom #1. Off limit areas are inaccessible to children by use of safety gates and doorknob covers. There is no fireplace on the premises. Co-Licensee utilizes the fenced back yard for outdoor activities. LPA informed Co-Licensee to ensure children are supervised at all times during outdoor activities. Co-Licensee stated there are no bodies of water and LPA did not observe any bodies of water during the inspection.
There are sufficient age appropriate toys, games, and play equipment available. The home was clean and orderly during inspection. Detergents, cleaning compounds, and medicines are inaccessible to children in care and poisons are to be locked away. The fire extinguisher is rated 3A:40B:C and located in the kitchen, smoke alarm and carbon monoxide detectors meet requirements and are operational. There is a working cell phone in the home. Co-Licensee stated there are no firearms, other weapons or ammunition on the property.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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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: SIMON, IMMACULA & RICHARD FAMILY CHILD CARE
FACILITY NUMBER: 376629029
VISIT DATE: 09/06/2022
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Co-Licensee maintains documentation of proof of control of property for review by the Department. Property Owner/Landlord Consent form LIC9149 is on file, signed by landlord and approves licensee to care for fourteen (14) children. Co-Licensee’s Mandated Reporter AB1207 training and expires on 09/01/2024. Pediatric CPR and First Aid certifications expire on 10/2022. Immunization records per SB792 were reviewed and met regulations. Required documents are posted.

All adults living or working in the home have been fingerprint cleared and associated. Facility roster was available and updated. A total of five (5) children are currently enrolled. Children's files were not available during inspection.Licensee will send copies to LPA. The last fire and disaster drill were conducted on 05/2022.

LPA reviewed the following with licensee: SIDS, car seat law, reporting requirements, shaken baby syndrome, care and supervision, and COVID-19 precautions/guidelines. Licensee was also reminded the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care.

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.

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.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
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: SIMON, IMMACULA & RICHARD FAMILY CHILD CARE
FACILITY NUMBER: 376629029
VISIT DATE: 09/06/2022
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Incidental Medical Services (IMS) policy was discussed. 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 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.
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. San Diego Regional Office Duty Line was provided: (619) 767-2248.

The maximum capacity for a Large Family Child Care home: 12 children (with a qualified assistant) with no more than 4 infants; or (with landlord consent) 14 children (with a qualified assistant) with no more than 3 infants, 1 child enrolled in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. When there is no qualified assistant, 14 years of age or present, the capacity reverts to the requirements for a Small Family Child Care.

No deficiencies were issued during today's inspection.
Increase in capacity was granted on this date.

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.

Exit interview conducted and report reviewed with Co-Licensee, Immacula and Richard Simon. Co-Licensees were provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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