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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628405
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:38:30 AM

Document Has Been Signed on 09/16/2021 11:38 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CAMPOS, LEONARDO FAMILY CHILD CAREFACILITY NUMBER:
376628405
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ofelia ZavalaTIME COMPLETED:
11:50 AM
NARRATIVE
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On September 16, 2021, at 10:00 a.m., Licensing Program Analyst (LPA), Casey Gulley conducted an unannounced Annual Required Inspection and met with staff member, Ofelia Zavala. LPA disclosed the purpose of the inspection and was granted entry into the facility by the staff member. Two (2) children and one (1) staff were present in the facility during this inspection. This facility is a one story, three bedroom, two bathroom house. Ofelia Zavala accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: bedroom one and living room. off limits areas are bedrooms two and bedroom three and are inaccessible through use of door knob covers..

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. The home has a fenced backyard available for outdoor activities. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications expired on March 2021. Licensee has required immunizations. Licensee completed Mandated Reporter Training on 7/8/2020 Facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 9/16/21.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Casey Gulley
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPOS, LEONARDO FAMILY CHILD CARE
FACILITY NUMBER: 376628405
VISIT DATE: 09/16/2021
NARRATIVE
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LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding upcoming Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: [email protected] . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

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.

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

An exit interview was conducted with the licensee. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Casey Gulley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPOS, LEONARDO FAMILY CHILD CARE
FACILITY NUMBER: 376628405
VISIT DATE: 09/16/2021
NARRATIVE
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An exit interview was conducted with the licensee. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

LPA provided notice of site visit and observed it being posted at the facility. Notice of Site Visit to be posted for 30 days.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Casey Gulley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2021 11:38 AM - It Cannot Be Edited


Created By: Casey Gulley On 09/16/2021 at 11:06 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPOS, LEONARDO FAMILY CHILD CARE
FACILITY NUMBER: 376628405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited
HSC
1596.866(2)(A)(B)

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1596.866(2)(A)(B) Additional health and safety training; condition of licensure – “… each family day care home licensee who provides care, shall have … training … shall include … Pediatric first aid … Pediatric cardiopulmonary resuscitation (CPR).” This requirement is not met as
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Licensee stated that he and staff member will enroll in course and submit a current CPR/ First Aid card by for verifacation by October 18, 2021.
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evidenced by: Based on LPA’s observation, the Licensee did not ensure current possession of a current First Aide/CPR card, which poses as a potential risk to children in care.
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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:Jason Garay
LICENSING EVALUATOR NAME:Casey Gulley
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


LIC809 (FAS) - (06/04)
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