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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216120
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:15:06 PM

Document Has Been Signed on 06/14/2022 04:15 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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
426216120
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Maria LopezTIME COMPLETED:
04:30 PM
NARRATIVE
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 6/14/2022, at 1:04 PM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection, with a change of capacity. LPA met with Maria Lopez, Licensee. The purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 1 infant and 4 children in care at the time of the inspection.

The main day care areas are living room, kitchen, dining room, and hallway bathroom. LPA observed the children's bathroom to be free of toxins. LPA observed the day care area to be clean and orderly. LPA observed age appropriate books, toy, games, tables and chairs. LPA observed the off-limits areas which include the 3 bedrooms, 1 bathroom, laundry room and attached garage, which are secured with door knob covers on the doors making the off limit areas inaccessible to children. The backyard is completely fenced. LPA observed age appropriate toys, and, play structure in the backyard. LPA observed a small outdoor dog

LPA observed weapons and ammunition secured in the home. Licensee stated she does not hold a foster family license. LPA reviewed the facility roster. LPA reviewed children's file, which revealed child #1 did not have a Safe Sleep Plan (LIC 9227) and Safe Sleep Chart. The fire extinguisher was observed and was serviced June 9, 2022. The carbon monoxide detector and smoke alarm that were tested and functioning at 1:42 PM, that meets statutory requirements. Licensee is current with immunization required per SB 792. The last Safety drill was conducted on May 24, 2022. Licensee is current with CPR and First Aid which expires October 15, 2023. Licensee completed the Mandated Reporter Training required per AB 1207, on February 8, 2021.

THIS REPORT CONTINUES ON LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216120
VISIT DATE: 06/14/2022
NARRATIVE
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On May 25, 2022, the Licensee submitted documentation for a FCCH change of capacity. The Licensee is seeking to change the FCCH’s capacity from 8 (Small FCCH) to 14 (Large FCCH). The Santa Maria Fire Department granted a fire clearance following an inspection completed at FCCH on June 10, 2022.

Licensee is not providing Incidental Medical Services. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: htttp://www.ada.gov/childqanda.htm

LPA reviewed with Licensee the Safe Sleep Regulation (PIN 20-24), What is Carbon Monoxide?, and The Effect of Lead. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided on line at www.ccld.ca.gov.

Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home and was advised to review Quarterly Updates and Provider Information Notices (PINs), Title 22 & Health & Safety Codes which can be accessed on-line athttps://www.cdss.ca.gov/inforesources/child-care-licensing

The home meets Title 22 of CCR requirements for a Large Family Child Care license effective today. Effective date of license is today June 14, 2022.



Today, deficiency cited under Title 22 Division 12 Appeal rights given. THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. LPA observed the "Notice of Site Visit" posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/14/2022 04:15 PM - It Cannot Be Edited


Created By: Martina Jimenez On 06/14/2022 at 02:52 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee stated she was unaware of the safe sleep log and has not documented labored breathing, signs of distress, body temperatures, or checking on them every 15 minutes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee will check and document the observation of infant every 15 minutes while infant is sleeping and provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022

[email protected]
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee stated she was unaware of the safe sleep log and has not documented labored breathing, signs of distress, body temperatures, or checking on them every 15 minutes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee will check and document the observation of infant every 15 minutes while infant is sleeping and provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022

[email protected]
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:Martina Jimenez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/14/2022 04:15 PM - It Cannot Be Edited


Created By: Martina Jimenez On 06/14/2022 at 02:52 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of file and interview, the licensee did not comply with the section cited above Child # 1 does not have Individual Safe Sleep Plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee agreed to discuss with parent the Safe Sleep plan and obtain the signature. Licensee to will submit provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022.
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of file and interview, the licensee did not comply with the section cited above Child # 1 does not have Individual Safe Sleep Plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Licensee agreed to discuss with parent the Safe Sleep plan and obtain the signature. Licensee to will submit provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022.

[email protected]
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:Martina Jimenez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/14/2022 04:15 PM - It Cannot Be Edited


Created By: Martina Jimenez On 06/14/2022 at 02:52 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on review of file and interview, the licensee did not comply with the section cited above Child # 1 does not have Individual Safe Sleep Plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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2
3
4
Licensee agreed to discuss with parent the Safe Sleep plan and obtain the signature. Licensee to will submit provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022.
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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4
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:Martina Jimenez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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