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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216160
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:13:08 PM

Document Has Been Signed on 08/10/2022 04:13 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
426216160
ADMINISTRATOR:MARYPAZ PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 863-3416
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
08/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marypaz PerezTIME COMPLETED:
04:20 PM
NARRATIVE
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On 8/10/22, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced visit for the purpose of conclude a complaint investigation. The purpose of this report is to document deficiency observed during this investigation.

Based on medical records, interview with Licensee and two (2) assistants it was determined that C1 had a medical emergency at the facility that required C1 to be picked up. Licensee, A1 and A2 reported being present in the facility during the incident and observing C1's eye was swollen. Licensee reported notifying parent/guardian right away. C1 was picked up and taken to emergency room for further evaluation. Licensee stated this incident was not reported to Community Care Licensing because she forgot.

Type B deficiency is being cited. California Code of Regulation, (Title 22 Division 12 and 102416.2(3)(b), is being cited on the attached LIC 809 D).

A closing interview was conducted with the Licensee. Licensee was provided and advised of their right to appeal. LPA informed Licensee of the need to provide a plan of correction to CCLD as well as the time which the plan of correction needs to be submitted to CCLD.

The Notice of Site Visit was provided to the Licensee as required by H&S Code Section 1596.817. The Notice of Site Visit must remain posted for 30 days or a civil penalty of $100.00 may apply.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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Document Has Been Signed on 08/10/2022 04:13 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 08/10/2022 at 02:26 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 426216160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2022
Section Cited
CCR
102416.2(3)(b)

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1597.467(b)(1) provides in part: "A report shall be made to the Department…following the occurrence during the operation of a family day care home of any of the following events: (B) Any injury to any child that requires medical treatment. This requirement was not met as evidenced by:
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Licensee agrees to train all assistants on reporting requirements. Licensee states that moving forward, she will ask the individual who observes the incident to call it in right away to Community Care Licensing. Licensee will still be responsible to sending in written report. Licensee agrees to submit a short summary via email
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Based on medical records, interview with complainant, Licensee and two (2) assistants, it was determined facility staff were aware C1 received medical attention and did not report this incident to Community Care Licensing. This is a potential risk to the health and safety of children in care.
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to [email protected] by 8/17/22.

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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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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