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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216015
Report Date: 09/29/2021
Date Signed: 09/30/2021 04:42:34 AM

Document Has Been Signed on 09/30/2021 04:42 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:MUNIZ FAMILY DAY CAREFACILITY NUMBER:
426216015
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Antoinette MunizTIME COMPLETED:
05:10 PM
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On 9/29/2021, Licensing Program Analyst Gigi Reyes conducted an unannounced Required Annual Inspection, met with Licensee Antoinette Muniz and discussed the purpose of the inspection. LPA asked pre health screening questions related to COVID 19, Licensee's responses indicate there are no COVID 19 exposure in the Family Child Care Home (FCCH).

LPA and Licensee toured the interior and exterior of the home, there were 4 children present, Licensee's 2 children and 2 niece(s)/nephew(s). Licensee stated she is not operational and caring only for family member's children from time to time. LPA explained that FCCH is due for annual inspection and inasmuch as CCLD did not receive LIC 9211 Request for Inactive Child Care License Status thus, inspection will be conducted.

LPA observed appropriate fire extinguisher which was purchased on 10/12/2021. Smoke and carbon monoxide detectors were tested and found functional. LPA observed clean, safe and age appropriate toys. The backyard is completely fenced. LPA observed age appropriate toys and play equipment. No bodies of water were observed on site.

LPA reviewed the following documents, Pediatric CPR and First Aid Card expires on7/2022. Licensee took the Mandated Reporter Training per AB 1207 on 6/10/2021. Licensee has proof of immunization per SB 792.
Continued on LIC 809 C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MUNIZ FAMILY DAY CARE
FACILITY NUMBER: 426216015
VISIT DATE: 09/29/2021
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LPA discussed Safe Sleep Regulations with Licensee. Providers must check on sleeping infants (0 to 24 months) every 15 minutes and document their condition Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

The Licensee is not providing Incidental Medical Services (IMS). Policy was discussed. 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: www.ada.gov/childqanda.htm

In the areas evaluated, no deficiencies cited.

Exit interview conducted with Licensee. Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing


Licensee submitted LIC 9211 Request of Inactive Child Care License Status effective September 22, 2021 to September 22, 2022.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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