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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216267
Report Date: 04/22/2022
Date Signed: 04/22/2022 10:55:22 AM

Document Has Been Signed on 04/22/2022 10:55 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CLARK FAMILY CHILD CAREFACILITY NUMBER:
426216267
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jana Helene ClarkTIME COMPLETED:
11:00 AM
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On April 22, 2022 at 8:50 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an announced a pre-licensing inspection and met with Applicant, Ms. Jana Clark. LPA asked pre screening questions related to COVID-19, applicant's responses indicate there were no COVID-19 exposure on site. LPA discussed the purpose of the inspection.

LPA in the company of the applicant toured the home inside and outside The home is a single story composed of 4 bedrooms, 2 baths, living room, family room, kitchen, backyard and garage. Based on the Facility sketch and applicant's statement stated the family room which is the main day care area, living room, dining area, kitchen, 1 restroom, 1 bedroom (playroom) will be accessible to children in care. Off limit areas are 3 bedrooms with child safety lock and enclosed with baby gate garage and laundry room.The 2A10 BC fire extinguisher was serviced on 2/23/2022, applicant was reminded that fire extinguisher should be serviced or to purchase a new one every year. There are carbon monoxide and a smoke detectors which were tested and found to be functional.

Ms. Clark completed the Family Child Care Home orientation on 12/17/2021, Preventative Health and Safety Training was completed on 3/9/2022. Pediatric 1st Aid/CPR certificate expires on 3/20/2024 and should be renewed every two years. LPA discussed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, Measles, including verification of TB. Applicant's immunization record is on file.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 426216267
VISIT DATE: 04/22/2022
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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.

The home/applicant meets the requirements for a Small Family Child Care Home under California Code of Regulation Title 22 Division 12. License was granted effective today, April 22, 2022.

Exit interview conducted and report was reviewed with the applicant, Ms. Jana Clark.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CLARK FAMILY CHILD CARE
FACILITY NUMBER: 426216267
VISIT DATE: 04/22/2022
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Ms. Clark completed the Child Abuse Mandated Reporter Training on 03/28/2022 and was reminded that it should be renewed every two years. LPA discussed COVID-19 Mitigation Plan/ and have applicant completed the COVID-19 Self Assessment Guide

Applicant, 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 applicant, 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 applicant 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

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. Children's record keeping requirements were reviewed.Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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