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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215683
Report Date: 11/15/2022
Date Signed: 11/15/2022 03:06:38 PM

Document Has Been Signed on 11/15/2022 03:06 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:SUEMY ARELY SERVINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 266-1416
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Suemy ServinTIME COMPLETED:
03:15 PM
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On 11/15/22, at 1:00 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an One Year Required unannounced Inspection of the abovementioned Family Child Care Home (FCCH). LPA met with Elisa Serna, Assistant of the FCCH and explained the purpose of the inspection. LPA, in the company of the Assistant, toured the interior and exterior of the FCCH. The Licensee of the FCCH, Suemy Servin, arrived shortly after the inspection commenced.

The FCCH is a five bedroom, three bathroom single story dwelling. The home’s living room, kitchen, hallway bathroom, converted guest rooms (two) and backyard are utilized for child care services, while the remainder of the home is excluded from child care. LPA observed child safety gate at the hallway leading to the master bedroom. LPA notes three children are present during the inspection.

The FCCH is orderly and clean. LPA observed the bathroom used by children in care to be clean and free of toxins. LPA observed cleaning compounds and medication in the FCCH stored in a secure laundry room. Sharps are located in an elevated kitchen cabinet. The FCCH has ventilation and sleeping accommodations to afford for child care. Toys, furniture and equipment in the FCCH are age appropriate.

Required forms and documents are posted on the wall near an entry sliding glass door. LPA observed a smoke and a carbon monoxide detectors in the FCCH. The detectors were not tested during the inspection as children in care were in different phases of sleep. LPA observed a regulation fire extinguisher (2A10BC) in the FCCH which was purchased on 9/8/22. LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually. LPA notes the FCCH has no fireplace.

The backyard of the FCCH is completely enclosed by wooden fencing. Footing in the backyard area is varied. LPA observed two sheds in the area which are inaccessible to children in care. Toys and play equipment
(CONT. 809-C, Page 2)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SERVIN FAMILY CHILD CARE
FACILITY NUMBER: 426215683
VISIT DATE: 11/15/2022
NARRATIVE
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in the backyard area are age appropriate. The Licensee is reminded to replace place toys and play equipment in the area when such items begin to degrade or are not in good repair. LPA observed no bodies of water on site.

LPA's record review revealed Licensee completed Mandated Reporter training on 10/11/21 (expiration 10/11/23) and Pediatric CPR/First Aid (EMSA approved) on 6/30/22 (expiration 6/30/24) . LPA reminded Licensee of obligation to maintain current training and certifications. LPA reviewed children's records. The records are current, complete and possessed emergency contact information as well as children immunizations. LIcensee has documentation memorializing child sleep checks in intervals of 15 minutes. A review of the FCCH's fire drill log show drills are current with the last occurring on 9/1/22. LPA observed a dog on site. The vaccination record for the dog was reviewed and found to be current.

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

Licensee 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.

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.

(CONT. 809-C, Page 3)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 11/15/2022
NARRATIVE
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A Notice of Site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee Suemy Servin.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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