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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009411
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:24:34 AM

Document Has Been Signed on 11/02/2023 11:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MATHEWS, SAMANTHA FCCHFACILITY NUMBER:
483009411
ADMINISTRATOR:MATHEWS, SAMANTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 486-6554
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 10DATE:
11/02/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee Samantha MathewsTIME COMPLETED:
11:35 AM
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An annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. A review of staff records on 11/01/23 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently two adults living in the home.

During today’s inspection the home and grounds were toured. The licensee and assistant were supervising 10 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 06:30AM to 06:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are all bedrooms in the home, the garage and the living room. They were made inaccessible by door locking mechanisms and/or child safety gates. The home was clean and orderly, and was at a comfortable indoor temperature. 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 12/2024. Both licensee and assistant have valid AB 1207 mandated reporter training certificates which expire in 2024. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. The regulation that poisons are locked with a key or combination lock was reviewed. The fireplace has been made inaccessible with a board and shelving. 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. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard. Six children's records were reviewed at 09:55AM; required emergency information was observed to be on file. Infants in care had safe sleep log on file. continued on 809-C
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MATHEWS, SAMANTHA FCCH
FACILITY NUMBER: 483009411
VISIT DATE: 11/02/2023
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee Samantha Mathews, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Samantha Mathews.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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