015701195-11-21-2025-52-CC-EWOS-DNMPAS-20251121100914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015701195
Report Date: 11/21/2025
Date Signed: 11/21/2025 10:09:30 AM

Document Has Been Signed on 11/21/2025 10:09 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	CAMPOS, GLORIA		FACILITY NUMBER:	015701195
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 6	DATE:	11/21/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Gloria Campos		TIME VISIT/ INSPECTION COMPLETED:	10:30 AM

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On November 21, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual/Random Inspection and met with licensee, Gloria Campos. LPA disclosed the purpose of the visit and conducted a health and safety inspection, touring the facility both inside and outside. Present during the inspection were the licensee’s fingerprint-cleared mother and brother. Also present were four preschool-age children, one school-age child, and one infant. The facility operates Monday through Friday, from 6:00 AM to 6:00 PM.

This single-story duplex, rented by the licensee, consists of three bedrooms, two bathrooms, a kitchen, living room, backyard, and a two-car garage. The home was observed to be clean, orderly, and equipped with proper heating and ventilation to ensure safety and comfort. There is a chimney located in the living room, which is barricaded to prevent children’s access. Per the licensee, the chimney is not used.

On-limit areas include:

Kitchen
Living room
Dining room
Main bathroom down the hallway
Rear yard

The isolation area will be a section of the dining area, away from other children in care.

Off-limit areas include:

All bedrooms
Front yard
A gated section in the rear yard (to the left)
Two-car garage

Off-limit areas will be made inaccessible through the use of closed and/or locked doors and visual supervision.

See LIC 809-C for continuance.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CAMPOS, GLORIA	FACILITY NUMBER: 015701195
	VISIT DATE: 11/21/2025

NARRATIVE

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At 8:20 AM, LPA inspected the backyard area and confirmed that no pools, hot tubs, or other bodies of water were present, in compliance with childcare licensing regulations. The outdoor play area is fully fenced and free of defects or hazardous conditions. A canopy provides shade and protection from direct sunlight. The play area includes a small slide with appropriate cushioning underneath, as well as age-appropriate play equipment.

LPA asked the licensee if she transports children in care. The licensee stated that she does and provided LPA with a current copy of her California Driver’s License. LPA also asked whether firearms were present in the home, and the licensee stated there are no firearms.

LPA inspected the cabinets in all on-limit areas, including the kitchen, living room, dining room, and main bathroom, and did not observe any hazardous materials or toxins accessible to children. LPA tested the dual smoke and carbon monoxide detector located in the living room and found it to be functioning properly. The home is equipped with a working telephone, a first aid kit, and a fully charged 3A40BC fire extinguisher, which meets State Fire Marshal standards.

At 8:40 AM, LPA reviewed two children’s files and one staff file. All children’s files contained the required Parent Notification—Additional Children in Care, Identification and Emergency Information, Notification of Parent’s Rights, and Consent for Emergency Medical Treatment forms. The staff file contained the required Employee Rights form and the Statement Acknowledging the Requirement to Report Child Abuse. During the review, LPA also verified the immunization records of the licensee and children in care and found the licensee to be in compliance with immunization laws applicable to childcare providers.

The licensee conducts and documents fire and disaster drills once every six months, with the most recent drill conducted on 10/13/2025. The licensee’s Health and Safety training is completed, and their CPR and First Aid certification is current, expiring in 08/2027. Additionally, the licensee completed mandated reporter training on 08/02/2024. The facility roster was reviewed and accurately reflects current children enrolled as well as those no longer attending the facility.

At approximately 10:00 AM, 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-andresources/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.

See 809-C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CAMPOS, GLORIA	FACILITY NUMBER: 015701195
	VISIT DATE: 11/21/2025

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Effective August 1, 2003, California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to children’s parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 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.

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.

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

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

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Gloria Campos.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC809 (FAS) - (06/04)

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