<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475407728
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:49:16 PM

Document Has Been Signed on 08/17/2021 02:49 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:LAWRENCE-SAMPSON FAMILY CHILD CARE HOMEFACILITY NUMBER:
475407728
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Laticia Lawrence & Kevin Sampson TIME COMPLETED:
03:00 PM
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
An Annual inspection was made to the facility by Licensing Program Analyst (LPA), Snow. A review of staff records on 8/17/21. indicates that all facility staff or other individuals who require caregiver background checks have NOT received criminal record and child abuse index clearances or exemptions. There are currently 2 adults living in the home.
The LPA arrived at the facility at 11:20 am and the lady (S1) who answered the door said Sampson does not live here and when the LPA asked if it was a daycare she said “wait” and closed the door. Over 20 minutes later at 11:45 the co-licensee Kevin Sampson arrived by vehicle. He said he had just gone to the store & allowed the LPA inside. The LPA observed 5 children in care including the licensees foster child with S1 in the garage playroom; S1 does not have the required criminal record clearance to assist with staff.
During today’s inspection the home and grounds were toured. No children were observed left in any parked vehicle. The facility’s operating hours are 6am to 5:30pm Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the master and were made inaccessible by a key. The home was clean and orderly, and was at a comfortable indoor temperature of 74. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 11/16/21. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: LAWRENCE-SAMPSON FAMILY CHILD CARE HOME
FACILITY NUMBER: 475407728
VISIT DATE: 08/17/2021
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
26
27
28
29
30
31
32
Poisons are locked in the laundry. The fireplace has been made inaccessible with cushioning. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection.
An infant C2) was observed sleeping in a chair upon arrival at 11:48 am and there are no sleep records for infants between 12-24 months.
The children use the back yard as the outdoor play area and is fully fenced. There were no pools or other bodies of water observed in the yard; there is a plastic kids pool and licensee is aware that no standing water is allowed.
Four children's records were reviewed at 1pm; required emergency information was observed to be on file. Children (C1&C2) did not have infant sleep records on file. The licensee is providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.
Notice of Site Visit shall be posted for 30 days from today's visit.
The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/17/2021 02:49 PM - It Cannot Be Edited


Created By: Jaime Snow On 08/17/2021 at 01:23 PM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: LAWRENCE-SAMPSON FAMILY CHILD CARE HOME
FACILITY NUMBER: 475407728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited
HSC
102370(e)(d)(1)

1
2
3
4
5
6
7
Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or
1
2
3
4
5
6
7
S1 shall not reside or work in the home until a criminal record exemption or clearance is received. Parents/guardians must sign Form LIC9224 to be kept in each child's file.
8
9
10
11
12
13
14
exemption. This requirement was not met as evidenced by staff (S1) left alone with 5 children (2 of them infants. This presents an immediate risk to children in care.
8
9
10
11
12
13
14

The Licensees say they understand and agree.
A $100 civil penalty was assessed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Erin Virrueta
LICENSING EVALUATOR NAME:Jaime Snow
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/17/2021 02:49 PM - It Cannot Be Edited


Created By: Jaime Snow On 08/17/2021 at 02:01 PM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: LAWRENCE-SAMPSON FAMILY CHILD CARE HOME
FACILITY NUMBER: 475407728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited
CCR
102425(j2d)&(i)

1
2
3
4
5
6
7
INFANT SLEEP If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.
The provider shall physically check on the infant every 15
1
2
3
4
5
6
7
The Licensee agrees to study the sleep requirements and send a statement of understanding by 8/24/21
The LPA will provide an email with resources by 8/18/21
8
9
10
11
12
13
14
minutes; Documentation shall be maintained in the infant’s file and be available to the Department for review. Requirement not met as evidenced by an infant sleeping in a chair and was not moved until asked & no sleep records avail. This poses immediate risk.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Erin Virrueta
LICENSING EVALUATOR NAME:Jaime Snow
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4