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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494255
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:02:07 PM

Document Has Been Signed on 08/27/2021 01:02 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SELVA DE CAMPOS FAMILY CHILD CAREFACILITY NUMBER:
197494255
ADMINISTRATOR:SELVA DE CAMPOS, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 384-8133
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Licensee-Alejandrin CamposTIME COMPLETED:
01:30 PM
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On 8/27/2021 Licensing Program Analyst (LPA), Dalicia Adkins conducted an unannounced Annual Required Inspection and was met by Licensee, Alejandrin Campos. Also present was staff #1 and staff #2. Days and hours of operation are Monday- Friday 7:30 am-5:30pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that the kitchen, and living room are not used for bathroom providing care and are inaccessible to children, these rooms and all other rooms made inaccessible by locked doors and or child security gates. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (323) 384-8133.

There are currently infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Dalicia Adkins
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SELVA DE CAMPOS FAMILY CHILD CARE
FACILITY NUMBER: 197494255
VISIT DATE: 08/27/2021
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Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.
Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.
LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 4/27/2019. Licensee’s pediatric CPR/First Aid expires on 03/2020. Licensee registered for CPR class while LPA was on site, licensee will began the online course 8/28/2021 and will send LPA Adkins a copy of card by 8/30/21. . A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.
Incidental Medical Services (IMS) not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.
LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.
This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Dalicia Adkins
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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