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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372010564
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:25:39 PM

Document Has Been Signed on 03/27/2023 04:25 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CLARK, CHAN FAMILY CHILD CAREFACILITY NUMBER:
372010564
ADMINISTRATOR:CLARK, CHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 225-1490
CITY:SAN DIEGOSTATE: CAZIP CODE:
92107
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 1DATE:
03/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chan ClarkTIME COMPLETED:
10:59 AM
NARRATIVE
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On 3/27/23 at 9:45am Licensing Program Analyst (LPA), Martha Malane conducted an unannounced case management deficiency inspection. Upon arrival, LPA met with Licensee, Chan Clark and disclosed purpose of the inspection. During the inspection there was one (1) infant child in care, Child 1 (C1).

At 9:54am, LPA observed Child 1 (C1) sleeping in a swing with two (2) blankets covering the infant; see LIC809D for Type A deficiency cited. Licensee stated she does conduct or log 15-minute checks for sleeping infants; see LIC809D for deficiency cited. During an annual inspection on 8/5/22, LPA and licensee discussed requirements for Safe Sleep. On 8/5/22, Technical Assistance, resources for safe sleep and a sample sleep log were provided to the licensee.

LPA informed Licensee, Chan Clark, that this report dated 3/27/23 documents two (2) Type A citations on the attached LIC809-D, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA informed licensee to provide a copy of this licensing report dated 3/27/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

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. Licensee acknowledged understanding of the requirements for criminal record clearances.

Exit interview conducted with Licensee, Chan Clark. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Martha Malane
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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Document Has Been Signed on 03/27/2023 04:25 PM - It Cannot Be Edited


Created By: Martha Malane On 03/27/2023 at 10:51 AM
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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CLARK, CHAN FAMILY CHILD CARE
FACILITY NUMBER: 372010564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2023
Section Cited
CCR
102425(i)

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102425 (i) If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.
This requirement is not met as evidenced by:
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Licensee stated she will place infants in a crib and follow safe sleep regulations as previously provided.
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Based on observation and interview, the licensee did not comply with the section cited above in that at 9:54am, LPA observed Child 1 (C1) sleeping in a swing, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/28/2023
Section Cited
CCR102425(j)

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102425 (j) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check
This requirement is not met as evidenced by:
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Licensee stated she will submit a copy of the safe sleep log for this week from 3/27/23-3/31/23 to the SDRO by COB 3/31/23
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Based on interview and record review, the licensee did not comply with the section cited above in not providing proof of document sleep for infants at the time of this inspection, which poses a potential health, safety or personal rights risk to persons in care.
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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:Tulam Vu
LICENSING EVALUATOR NAME:Martha Malane
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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