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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216015
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:33:24 PM

Document Has Been Signed on 02/21/2024 03:33 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:MUNIZ FAMILY DAY CAREFACILITY NUMBER:
426216015
ADMINISTRATOR:MARIA ELENA MUNIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 862-9417
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
02/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Antoinette MunizTIME COMPLETED:
03:40 PM
NARRATIVE
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On 2/21/2023 at 10:00 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced case management inspection and met with Licensee Antoinette Muniz. The purpose of the inspection is to conduct a Confirmation of Removal (COR) for Individual#1 and to ensure Individual #1 is not present at the facility. At 12:30 PM due to technical issues, LPA left the facility and returned at 2:50 PM. There were total of 8 children present under the care of Licensee and assistant.

On 2/9/2024, the Department notified the facility that Individual #1 does not have a criminal record clearance and Individual #1 cannot work, reside, or be present at the facility unless a criminal record exemption is granted. An exemption denial letter was mailed.

During today’s inspection, LPA accompanied by Licensee toured the entire home, LPA did not observe Individual #1 and their belongings. Per Licensee, Individual #1 does not reside or work at the facility. Licensee stated that Individual #1 left the residence on February of 2023. Licensee provided LPA a copy of the signed Confirmation of Removal for Individual #1 (LIC 300B). Licensee is informed she is required to notify parents of children currently in care that this individual has been removed from the home.



Verification of removal is complete.

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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: 02/21/2024
NARRATIVE
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 Licensee has to copy the Addendum To Notification of Parent's Rights (LIC 995B) for each child in care. Licensee issued a declaration (LIC 855) stating that the Individual no longer resides in the home and court has ordered a restraining order.

During the inspection, LPA observed an adult in the home, and was introduced to LPA by Licensee and referred to as Adult 1. Licensee stated that Adult 1 moved in to FCCH on February 10, 2024 as a renter. Adult #1 has not obtained a criminal record check/clearance.

Today, deficiency was cited under Title 22 Division 12. (LIC 809D). A civil penalty of $500.00 was assessed.

LPA Reyes informed licensee Ms. Muniz that this report dated 2/21/2024 documents a Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.
Also, LPA Reyes informed the licensee, Ms. Muniz to provide a copy of this licensing report dated 2/21/2024 that documents any Type A citation to parents/guardians of all children currently enrolled, by the next business day or the next 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 (LIC 9224), or other written statement, must be placed in the child's file for verification.

Continued on LIC 809 C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2024 03:33 PM - It Cannot Be Edited


Created By: Gigi Reyes On 02/21/2024 at 01:15 PM
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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: MUNIZ FAMILY DAY CARE
FACILITY NUMBER: 426216015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
102370(d)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
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Licensee agreed to have the individual obtain today a criinal record clearance and to submit a written plan of correction to CCL to prevent this event from recurring.
[email protected]
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During today's inspection LPA observed Adult #1 in the home. Licensee stated that Adult #1 moved in to the home on 2/10/2024 as a renter, and has not obtained a criminal record clearance. This poses an immediate risk to health and safety of children in care. A civil penalty of $500.00 was assessed.
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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:Maria Mueller
LICENSING EVALUATOR NAME:Gigi Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MUNIZ FAMILY DAY CARE
FACILITY NUMBER: 426216015
VISIT DATE: 02/21/2024
NARRATIVE
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During the inspection, while day care children were playing in the backyard, the licensee mentioned the presence of gophers, which the LPA overheard. The licensee explained that despite efforts, the gophers kept coming out. LPA observed some areas with visible gopher wires to prevent the gophers from coming out. LPA recommended that licensee avail professional services to eliminate the gophers, Licensee agreed to LPA's recommendation, however, licensee stated that neighbors also have gophers and they just move around the neighborhood.

A technical assistance was provided to Licensee.

Exit interview conducted and report was reviewed with Licensee, Ms. Muniz.

Notice of Site Visit was issued. The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Copies of this report must be posted for 30 days in a visible location for the authorized representatives of children.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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