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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216201
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:08:40 PM

Document Has Been Signed on 01/27/2023 02:08 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:
426216201
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
01/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Leticia LopezTIME COMPLETED:
02:15 PM
NARRATIVE
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On January 27th 2023, at 12:42PM Licensing Program Analyst (LPA) Rosie Breault made an unannounced Case Management – Annual Continuation inspection. LPA met with licensee Leticia Lopez and advised of nature and purpose of inspection. At the time of the inspection, there was one (1) child present (grandchild only), licensee, husband, and daughter.

This is a single story three (3) bedroom, two (2) bathroom home. Home consists of bedrooms, bathrooms, kitchen/dining room, living room, garage, and back yard.

On limit areas are identified as: living room, kitchen/dining room, and back yard.


Off limit areas are identified as: all bedrooms, all bathrooms, and garage.

Licensee has required documents posted in a prominent place. LPA observed the home to be clean, and orderly with heating and ventilation. LPA observed age-appropriate toys, and equipment readily accessible to children. LPA did not observe any hazardous toxins accessible to children. Back yard had ample shade for children and age-appropriate toys and play equipment. No bodies of water are present. Smoke and carbon monoxide detectors were tested at 1:16PM and were functioning at the time of the inspection. Fireplace is present in the living room room, and inaccessible to children by gate. Licensee stated no firearms or ammunition are present in the home.

CONTINUED ON LIC809C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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 01/27/2023 02:08 PM - It Cannot Be Edited


Created By: Maryrose Breault On 01/27/2023 at 01:21 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: 426216201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
102417(g)(1)

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The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.
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Licensee to either purchase or service fire extinguisher by Feb 2nd 2023 and provide either proof of purchase or service ticket to LPA at: [email protected]
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This evidence is met by...

Licensee last service date of fire extinguisher was 1/19/2022
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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:Ana Tolentino
LICENSING EVALUATOR NAME:Maryrose Breault
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023


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: 426216201
VISIT DATE: 01/27/2023
NARRATIVE
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A sampling of children and staff records was conducted. Children’s files were found to be incomplete. Identification and Emergency Information and Parent Rights were not present in C2 file. C1 did not have 15-minute sleep log. Licensee indicated she does not check every fifteen (15) minutes and record. Licensee file was found to be in order. Infant and Adult CPR/ First Aid expires 6/25/2024. Mandated Reporter expires 10/15/2023. Last fire drill was conducted on 9/29/2022. Regulation fire extinguisher was last serviced on 1/19/2022. Licensee was reminded to service or purchase a new fire extinguisher yearly.

LPA provided courtesy LIC 995A (Parent Rights), LIC9227 (Individual Sleeping Plan), Infant Sleep Record Chart and Safe Sleep FAQ’s in Spanish.

LPA discussed the safe sleep regulations with [applicant, licensee, or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed [applicant, licensee, or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

CONTINUED ON LIC809C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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: 426216201
VISIT DATE: 01/27/2023
NARRATIVE
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Licensee and husband both stated husband does not reside in home (LPA reviewed California Driver’s License and address does not match FCCH) and confirmed he is not fingerprinted at this time. LPA informed both licensee and husband, during childcare hours husband is not allowed in FCCH or he must obtain criminal record clearance or exemption. At the time of the inspection, there were no children present, only family.

Type B and Technical attached.

Exit interview conducted and copy of report provider to licensee.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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