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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415104
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:16:35 PM

Document Has Been Signed on 06/14/2022 02:16 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HAMPTON, PAULAFACILITY NUMBER:
013415104
ADMINISTRATOR:HAMPTON, PAULAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 428-2711
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Paula HamptonTIME COMPLETED:
01:20 PM
NARRATIVE
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On June 14, 2022 Licensing program Analyst (LPA) Indira Loza arrived at the facility to conduct an annual random inspection. Present for the inspection were the Licensee, Licensee's assistant (Betty Staples), two Preschoolers, two School-Age children, Licensee's grandson, and the grandson's pet dog. The home was inspected to conduct a Health and Safety check. Operating hours are Monday through Friday 7:30am to 6pm.

The home is a two story home consisting of a living room, dining room, kitchen, two upstairs bedrooms, two downstairs bedrooms, four bathrooms, an unfenced front area, a garage and fenced backyard due to construction. The child care area is near the fenced back yard. The off limit areas are the entire upstairs, unfenced front area, downstairs bedrooms and garage. The on limit areas are in the downstairs portion of the home, which are the bathroom, kitchen, small living area next to the kitchen, and the larger living room to the left of the bathroom.

The Licensee’s Pediatric CPR and First Aid training has been completed and expires November 2023. LPA obtained the children’s files for review and the children's roster. Last Fire Drill was conducted April 22, 2022.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months
*****************************************Report Continues on LIC 809-C*******************************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HAMPTON, PAULA
FACILITY NUMBER: 013415104
VISIT DATE: 06/14/2022
NARRATIVE
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and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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: 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.
Licensee was reminded that all adults 18 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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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
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 issued a Type A and a Type B citation. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Paula Hampton.

****************************************Report Continues on LIC 809-C******************************************

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/14/2022 02:16 PM - It Cannot Be Edited


Created By: Indira Loza On 06/14/2022 at 12:09 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HAMPTON, PAULA
FACILITY NUMBER: 013415104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as her grandson was in the presence of the daycare children and did not have Criminal Record Clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee will have her grandson be fingerprinted and send a copy of the LiveScan to LPA Loza via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/14/2022 02:16 PM - It Cannot Be Edited


Created By: Indira Loza On 06/14/2022 at 12:09 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HAMPTON, PAULA
FACILITY NUMBER: 013415104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above as two out of two staff did not have the Mnadated Reporter certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee will complete the Mandated Reporter training and send the certificate to LPA Loza via email by June 30th.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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