426216267-4-3-2023-17-CC-GRES-CQJP9N-20230403110724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426216267
Report Date: 04/03/2023
Date Signed: 04/03/2023 11:07:39 AM

Document Has Been Signed on 04/03/2023 11:07 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 CARE		FACILITY NUMBER:	426216267
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 2	DATE:	04/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jana Helene Clark		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 3, 2023 at 9:15 AM, Licensing Program Analyst Gigi Reyes conducted an unannounced One (1) Year Required inspection at a Family Child Care Home (FCCH) owned and operated by Jana Clark . The inspection was conducted to evaluate the facility's compliance with the licensing regulations and Health and Safety Code.LPA asked pre-screening questions related to COVID-19, and the licensee's responses indicated that there were no COVID-19 exposures on site. The facility had 2 infants present during the time of inspection. LPA discussed the purpose of the inspection with the licensee. During the inspection, LPA toured the interior and exterior of the facility. LPA observed that required licensing forms were posted in the wall by the day care area, in the right side of the entrance door. Smoke and carbon monoxide detectors were tested and found functional. The regulation fire extinguisher was serviced on 2/1/2022, the licensee was reminded that it should be serviced every year or a new one should be purchased. The facility conducts and documents fire and disaster drill every 6 months, and the last drill was conducted on 12/7/2022.The backyard of the FCCH was enclosed with a wooden fence and bushes. LPA observed appropriate toys and equipment. No bodies of water were observed on site. The licensee stated that there were no guns or ammunition in the home. LPA reviewed the facility file and found that the Pediatric CPR and First Aid certificate expires on 3/2024. The licensee's Mandated Reporter Training Certificate will expire on 3/20/2024. LPA reminded the licensee that AB 1207 should be renewed every two years. Continued on LIC 809 C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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: 04/03/2023

NARRATIVE

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The FCCH has a current roster of children in care, and a sampling of children records were reviewed and found to be current. The facility file contains Emergency and Identification card requirements. However, the licensee does not have liability insurance and had signed waivers in each child's file. LPA observed that an Individual Infant Sleep Plan (LIC9227) is maintained in the FCCH, and the licensee physically checks and documents the condition of the sleeping infant every 15 minutes.

A deficiency was cited under Title 22 Division 12 and it was documented in LIC 809 D.

Overall, the facility was found to be in compliance with most of the licensing regulations and Health and Safety Code. The deficiency cited can be addressed through the submission of a plan of correction, and it is expected that the facility will continue to operate in compliance with the licensing regulations and Health and Safety Code.

Licensee does not provide Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
Continued on LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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: 04/03/2023

NARRATIVE

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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 year old 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.

Appeal Rights were given and discussed.

Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

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

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/03/2023 11:07 AM - It Cannot Be Edited

Created By: Gigi Reyes On 04/03/2023 at 10:45 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: CLARK FAMILY CHILD CARE	FACILITY NUMBER: 426216267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, fire extinguisher was last serviced on 2/23/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	The licensee agreed to submit a plan of correction to Community Care Licensing (CCL) no later than 4/13/2023. gigi.reyes@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Maria Mueller

LICENSING EVALUATOR NAME:

Gigi Reyes

LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

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