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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215683
Report Date: 09/27/2021
Date Signed: 09/27/2021 02:07:31 PM

Document Has Been Signed on 09/27/2021 02:07 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SERVIN FAMILY CHILD CAREFACILITY NUMBER:
426215683
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Suemy Arely ServinTIME COMPLETED:
02:15 PM
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On 9/27/21, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced Required Inspection of the facility. Prior to entering the facility, LPA conducted pre-screening COVID-19 questionnaire and based on Licensee’s responses it was determined that the facility is safe and free from any COVID-19 exposures. LPA meet with Suemy Arely Servin, Licensee of the facility and explained the purpose of the inspection. LPA in the company of the Licensee, toured the interior and exterior of the home. This is a three (3) bedroom, three (3) bathroom home. Licensee stated that children have access to the living room, dinning room, one (1) bedroom, bathroom and backyard. Off limit areas include kitchen that is blocked off by a small baby gate, two (2) bedrooms that are also made inaccessible by a baby gate and attached studio. During the time of the inspection, Licensee was caring for three (3) children, one (1) child was picked up by parent during this inspection. When LPA completed the inspection, Licensee was caring for two (2) children.

LPA observed required forms posted in the kitchen of the facility. LPA observed a combination smoke and carbon monoxide detector in the hallway of the facility. Detector was tested by Licensee at 12:55 PM and was functional. The home has a regulation fire extinguisher which was serviced 6/2/21. LPA reminded Licensee that fire extinguisher needs to be either service or purchase annually. The home maintains working telephone services.

LPA observed that the facility is orderly, clean and has ventilation for child care services. LPA observed one fireplace in the facility that is made inaccessible to children in care by a gate. LPA observed a small gate at the entrance of the kitchen, making the kitchen inaccessible to children in care. LPA observed stored sharps in a cabinet in the kitchen that are not accessible to children in care. LPA observed all cleaning supplies and toxins are stored in the laundry room that is inaccessible to children in care. Medications in the facility are stored in Licensee's room which is also off-limits to children in care. LPA observed that bathroom used for children is clean and orderly and has plenty of hand soap and paper towels for the children in care. Toys and equipment observed in the facility are age appropriate. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SERVIN FAMILY CHILD CARE
FACILITY NUMBER: 426215683
VISIT DATE: 09/27/2021
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Licensee stated that children have access to the backyard. LPA observed that back yard is completely fenced. Licensee stated that when children are outdoors, children are always supervised by an adult. LPA observed plenty of shade and gross motor activities for children in care. LPA observed one (1) locked shed outdoors that is used to store day care material. LPA observed a built in permanent shed that stores gardening supplies and is made inaccessible by a small gate. No bodies of water were observed on site. Licensee stated there are no guns and ammunition in the facility.

A sampling of the children's record was reviewed and found to have current and up to date with emergency information cards and personal rights. Licensee’s records were reviewed and found to be current and up to date. Licensee CPR/First Aid certifications expires 7/18/22. Licensee’s AB1207 certificate expired 12/5/20. Licensee was unaware that AB1207 certificate had to be renewed every two years. Licensee agrees to renew by the end of this week. LPA informed Licensee that AB1207 must be updated every two years for every individual that works with children. Licensee is current with all immunization.



The Licensee is not providing 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: www.ada.gov/childqanda.htm

LPA discussed COVID-19 guidance and best practices with the Licensee. During this inspection, Licensee wore a face mask. Licensee stated that the facility is following all COVID-19 guidance. Licensee was reminded that it is Licensee's responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov. LPA and Licensee discussed safe sleep regulations. Licensee shared that at the moment she does have infant age children enrolled for services and is keeping a 15 minute log documenting the infant's sleep. LPA provided a copy of new Safe Sleep Regulations and LIC 9227 Individual Infant Sleep Plan and reviewed with Licensee.

In areas evaluated, there were no deficiencies cited during today's visit.

LPA provided Licensee with Notice of Site visit (LIC 9213) which was posted by the Licensee.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
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