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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215264
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:23:04 PM

Document Has Been Signed on 01/20/2023 02:23 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CLARK FAMILY CHILD CAREFACILITY NUMBER:
566215264
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kristin ClarkTIME COMPLETED:
02:40 PM
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On January 20, 2023 at PM, Licensing Program Analyst (LPA), Laura Villanueva conducted an unannounced Case Management-Licensee Initiated. LPA conducted the Covid-19 screening questions prior to entering the facility. LPA met with licensee Kristin Clark and ajdvised the purpose of the inspection. Licensee provided LPA a tour of the home inside and out. There were 4 children in care at the time of the inspection.

Licensee is requesting an increase in capacity from a small family child care license to a large license. A fire clearance was granted 10-1-22. Licensee completed Mandated Reporter Training on 10-10-22. The AB1207 fire extinguisher was serviced 1-13-22. Licensee will schedule an appointment to have the fire extinguisher serviced. Licensees CPR-First Aid has an expiration date of 1-4-23. Licensee is scheduled to complete a CPR-First Aid class on 1-24-23.

The home is 4 bedroom, 2 bath one story home. The children have access to a bedroom, office room, play room, hall restroom, and back yard. Fire place inside the living room is screened to prevent access by children. Kitchen cabinets were locked and knives are being kept out of reach from children. Back yard is enclosed with chain link and brick walls. LPA observed in ground pool in the back yard that was locked and surrounded by 5 feet tall metal poles, mesh panels, and an outward swing gate. The pool is completely inaccessible to children. LPA did not observe any hazards/toxins items accessible to children in care.

A large license is granted effective today. LPA provided Licensee a chart of capacity regulations for her reference. A notice of site visit was given to be posted for 30 days. No deficiencies cited.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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