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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216015
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:34:17 AM

Document Has Been Signed on 03/05/2024 11:34 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:MARIA ELENA MUNIZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 862-9417
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Antoinette MunizTIME COMPLETED:
11:35 AM
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On March 5, 2024, 9:40 AMLicensing Program Analyst, (LPA) Gigi Reyes conducted an unannounced Case Management inspection at the above Family Child Care Home (FCCH) LPA met with Licensee Antoinette Muniz and explained the purpose of the inspection.LPA and Licensee toured the home and observed 6 children under the care of Licensee.

On 2/21/2024 FCCH was cited under California Code of Regulations (CCR) 102370(d)(1) Criminal Record Clearance, 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.The tenant, Rebecca Romero has no Criminal Record Clearance at that time.

During today's inspection, Licensee stated Rebecca Moreno leaved the home, and no longer resides in her home, Ms. Moreno is currently staying at her adult child's residence. LPA observed that couch, bed, paintings and other big equipment in the converted garage. Licensee is aware that Rebecca Moreno cannot reside in the home until her Criminal Record Check is obtained.

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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: 03/05/2024
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The licensee submitted a declaration confirming that Rebecca Moreno is not residing in the home and acknowledging her understanding that a repeat violation of the same offense could jeopardize her FCCH license. The licensee also acknowledged that violation of the CCR my affect her license.

No deficiency was cited.

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 in a visible location.

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: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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