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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215683
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:55:39 PM

Document Has Been Signed on 09/23/2022 01:55 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: 8CENSUS: DATE:
09/23/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Suemy Arely ServinTIME COMPLETED:
02:15 PM
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 9/23/22, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced Case Management inspection of the above referenced Family Child Care Home (FCCH) for a change of capacity inspection. LPA met with Suemy Arely Servin, Licensee of the FCCH and explained the nature/purpose of the inspection. LPA notes that there were two (2) infant age children present during this inspection.

During this inspection, LPA and Licensee together toured the and interior and exterior of the FCCH. LPA observed the FCCH's interior and exterior to be free of hazardous materials and/or toxins at the time of the visit. LPA observed sharps and cleaning compounds located in the kitchen closet that has a safety latch and is off limits to the children in care. Medication in the home is kept in the home's bedrooms that off limits to children in care by means of a baby gate and door safety knobs. LPA observed and tested carbon monoxide and smoke detector at 1:45 PM and were operable.

LPA reviewed the Licensee’s First Aid/ CPR certification which expires on 06/30/24. LPA observed a regulation fire extinguisher which was purchased today 9/23/22. LPA reviewed the Licensee’s Mandated Reporter Training certificate, which was completed on 10/11/21. LPA reviewed control of property, mortgage deed.

On 06/27/22, the Licensee submitted documentation for a FCCH change of capacity. The Licensee is seeking to change the FCCH’s capacity from 8 (Small FCCH) to 14 (Large FCCH). The Santa Maria Fire Department granted a fire clearance following an inspection completed at FCCH on 09/12/2022.

LPA reviewed the handout "A Child Care Provider's Guide to Safe Sleep" (PIN 20-24), The Effects of Lead Exposure, and What is Carbon Monoxide. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SERVIN FAMILY CHILD CARE
FACILITY NUMBER: 426215683
VISIT DATE: 09/23/2022
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LPA provided a Handout for Reporting Child Abuse and Neglect Training provided online at www.ccld.ca.gov

The home meets Title 22 of CCR requirements for a Large Family Child Care license effective today. Effective date of license is today 9/23/22. LPA provided the Licensee a Notice of Site Visit (LIC 9213) to be posted.

THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. LPA observed the "Notice of Site Visit" posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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