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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500835
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:06:28 PM

Document Has Been Signed on 05/31/2024 01:06 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AFFONSO, SAMANTHAFACILITY NUMBER:
394500835
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Licensee, Samantha AffonsoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On May 31, 2024, Licensing Program Analysts Elizabeth Santiago (LPA) met with Licensee, Samantha Affonso for the purpose of conducting a case management inspection to increase the facility capacity. Licensee applied to change from a Small Family Child Care Home to a Large Family Child Care Home. Fire clearance was granted by Stockton Fire Department on 05/23/2024.

At time of inspection, LPA conducted an annual inspection as well. LPA observed six children present in the home at the time of the inspection and an assistant. Licensee's operating hours are Monday through Friday 23 hours per day. LPA verified the annual fees are current.

All adults living and working in the facility have a criminal record clearance. 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.

A health and safety inspection were conducted in all areas accessible to children. Off-limits areas include entire second floor, on the three sheds in the backyard. Licensee requested to have On-limits bedrooms #1 on the first floor. LPA observed the required postings and a working phone. 2A10BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives were inaccessible to children in care. LPA observed play room area with age appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care.

Continues on LIC809-C......
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AFFONSO, SAMANTHA
FACILITY NUMBER: 394500835
VISIT DATE: 05/31/2024
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........Continued from LIC-809........(Page 2)
Licensee stated there are weapons in the home. LPA verified that weapons and ammunition were stored in separate locked safes in off limit area.

The backyard has an in-ground pool area that is fenced per Title 22 regulations and LPA observed the gate to self-close and self-latch. There are windows that provide direct access into the pool area. There are safety locks on the windows and are alarm activated if opened.

Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. Licensee's immunization records are available in the facility file. Current EMSA pediatric CPR and First Aid certification was verified and expires on 03/2025 and Child Care Provider Mandated Reporter certification was verified and expires on 05/2025.

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.

LPA observed the requirement to check and log infant napping every 15 minutes. LPA observed copies of LIC 9227 Individual Sleeping Plan for infants under 12 months.

This facility is not currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed.

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SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AFFONSO, SAMANTHA
FACILITY NUMBER: 394500835
VISIT DATE: 05/31/2024
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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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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.

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/inspection-process

Continues on LIC809-C.....
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AFFONSO, SAMANTHA
FACILITY NUMBER: 394500835
VISIT DATE: 05/31/2024
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Exit interview conducted and report was reviewed with the licensee. During the exit interview, Licensee confirmed that there are no registered sex offenders (RSO) living in the facility and LPA completed the RSO profile in the Field Automation System. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.

Effective today 05/31/2024, facility is approved for a Large Family Child Care License to serve capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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