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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418849
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:20:00 PM

Document Has Been Signed on 09/28/2023 02:20 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SANTIAGO FAMILY CHILD CAREFACILITY NUMBER:
197418849
ADMINISTRATOR:SANTIAGO, HERMELINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 492-2064
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH: Hermelind SantiagoTIME COMPLETED:
02:45 PM
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On 9/28/2023, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required annual inspection at the Santiago Family Child Care Home. Upon arrival, the LPA met with the licensee, Santiago Hermelind an Licensee’s son (Carlos Santiago Olivas), who guided the LPA on a tour of the facility. Family members residing in the home include 3 adults (licensee, licensee's husband, adult son) and no children. When LPA arrived to the facility, MaElena Alverez (assistant) opened the door. The licensee was upstairs. LPA checked the Guardian associated list. MaElena’s name is not associated with the facility. According to Hermelind, her assistant was sick. MaElena is here for 1 week
This is a large family childcare facility. The hours of operation are Monday through Sunday, 24/7. During the inspection, LPA observed 4 childcare children (1 school-age and 4 preschools) with Licensee. Per the Licensing Information System, annual facility fees were current. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS at this time.
The home is set up as follows: This is a two-story, 4-bedroom, 2.5-bathroom home with kitchen/dining, family room, living room, laundry room and garage. The following areas are used for daycare:
Daycare is provided in the living room and family room. Children use the bathroom in the hallway on the right. Children have access to the living room and family room.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
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Off-limit areas include all bedrooms, bathrooms 1.5 (upstairs), laundry room, backyard and garage (accessed through laundry door). There is a barricade present on the bottom and top staircase; The licensee did not have the gate on. LPA remined the licensee the barricade(s) must remain in place during daycare hours if there are children under 5 years old in care.
· Living Room/ Family Room: In the playroom (Living room), the designated playroom, there are adequate age-appropriate toys, books, games, and napping mats/hygienic diaper changing equipment. PA observed age-appropriate toys and furniture for the children. There are games and books on the premises of this facility. The carpets and other materials were observed to be in good condition.
· Children's bathroom: Children will use the bathroom down the hall to the right. The bathroom was the tour. The bathroom was clean, sanitized, and in good repair. The toilet was inspected, and the sink/toilet is in operable condition. The toilet and faucets are clean, safe, and operable. The bathroom was observed to be free and clear of hazardous items.
· Kitchen/Dining Room: The kitchen was inspected to ensure dangerous items were inaccessible to children (Safety latches). All sharp utensils, poisons, and medications are unavailable to children in the kitchen, with child safety latches on cabinet doors and drawers. Sharp knives are kept in a butcher block in the gated kitchen.
· Backyard: The backyard was inspected; There is a new area for the family member with BBQ and relaxing area. The licensee the children do not use the outdoor backyard for outside play.
Other:
· AC/Heating Unit / Swamp Cooler unit was observed. The AC/Heating Unit is located on the right side of the home and is inaccessible to children via barrels blocking access to the AC unit. / The swamp cooler unit is inaccessible to children.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
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· Bodies of water: Per the licensee, there were no bodies of water in the home. There is a decorative water fountain that has no water.
· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
· Food: The licensee is enrolled in the Food program. The licensee will provide Breakfast, lunch, and snacks. Or the food is brought from home. The containers were labeled with the children’s names and properly stored or refrigerated.
· Fire extinguisher (2A10BC): LPA observed a required fire extinguisher (2A10BC) reading in Green and located in the kitchen, inaccessible to children. It meets standards established by the State Fire Marshall.
· Fireplace: The fireplace was observed in the living room and is screened to make it inaccessible to the children.
· Hanging window blind cords: The cords are inaccessible to children.
· Isolation area (Illness): Per the licensee, if the child shows signs of illness, they will be separated from other children and stay in Dining Room.
· Medications and cleaning solutions: Detergents/cleaning compounds are in the upper kitchen cabinet, inaccessible to the children. Medications are in the off-limits bedroom.
· Napping: Children will nap in designated areas with adult supervision. LPA observed 10 mats in the closet.
· Overnight Care: According to the licensee does not provide overnight care.
· Pets: No pet
· Phone service: There is a working landline or cell phone.
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
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· The First Aid kit is in the key-locked closet, inaccessible to children. The First Aid Kit was observed to be complete with supplies and a first aid manual.
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license, valid vehicle insurance, and vehicle registration.
· Weapons or Firearms: Per the licensee, there are No Firearms at the facility at this time. LPA does not observe any firearms.
LPA reviewed the following Documentation:
· Child files: LPA reviewed 8 children's records. The records are incomplete and missing forms. Or LPA observed that 8 children's files and the records were found to be in order.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with an expiration date (of 11/2023).
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and performed on 02/03/2020. OR no current facility earthquake/fire drill documents were observed during this inspection.
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: There are 4 infants enrolled in the facility. The licensee does not have LIC 9227 and Sleeping log in the files. LPA shared the Safe Sleeping Regulation with the licensee. During the visit, LPA no children were sleeping. There are pillows inside the cribs.
· The licensee (does not) post all required information.
· Mandated Reporter Training: The licensee has completed and renewed the online mandated reporter training at www.mandatedreporterca.com on 4/5/24.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
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The following information was discussed with the licensee:
o Mandatory Forms for the children's and assistant files.
o The licensee is reminded that 100% supervision is required for children at all times.
o Capacity, Roster requirements, and Documentation requirements for disaster drills (fire and earthquake).
o Licensee was made aware that it is their responsibility to know the regulations and anyone who assists in providing care. The licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
o Licenses were advised of the requirement to report unusual incidents and injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B.
o The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
o A baby walker shall not be allowed on the premises of a family childcare home in accordance with Health and Safety code sections 1596.848(b) and (c). State law prohibits baby walkers, bouncy seats, exersaucers, and other items that fall into that category.
o Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
NARRATIVE
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o The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban).
o Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations.
o Our Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
o To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
o Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 6 of 14
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849
VISIT DATE: 09/28/2023
NARRATIVE
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o LPA discussed the safe sleep regulations with the 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 the licensee [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.
o A notice of site visit was given and must remain posted for 30 days.
o The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m.

Deficiencies cited: (See LIC 809D). The following Type A and B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and Health & Safety codes.

Exit interview conducted and report was reviewed with the licensee, Hermelind Santiago.


SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 09/28/2023 02:20 PM - It Cannot Be Edited


Created By: Carol Heath On 09/28/2023 at 01:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed a lady (Ma. Elena Alvarez) does not have her lifescan and does not show on the facility assistant list, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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The assistant left during the inspection. The licensee agreed Ma. Elena will not return to the facility until she is associate with children,
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 09/28/2023 02:20 PM - It Cannot Be Edited


Created By: Carol Heath On 09/28/2023 at 01:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed the staired gate is not use during the operation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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The licensee agreed to put the gate on during the operation hour.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed the last Fire drill and Earthquake was conducted 3/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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The licensee agreed to conduct the fire drill and earthquake drill by next week and document the log.
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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 09/28/2023 02:20 PM - It Cannot Be Edited


Created By: Carol Heath On 09/28/2023 at 01:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed 4 cribs and all have pillows and blanket inside the crib. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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The licensee removed all the pillows out the cribs.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA asked for 4 children's files who attended the facility today. The licensee was unable to provide 3 children's file,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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2
3
4
The licensee agreed to email the children's paperwork by next Friday.
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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 09/28/2023 02:20 PM - It Cannot Be Edited


Created By: Carol Heath On 09/28/2023 at 01:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview,record revie, thwe licensee did not comply with the section cited above. 4 young children (Infant) do not have any paperwork,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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2
3
4
The licensee agreed to submit all the paperwork by next Friday.

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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 11 of 14
Document Has Been Signed on 09/28/2023 02:20 PM - It Cannot Be Edited


Created By: Carol Heath On 09/28/2023 at 01:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SANTIAGO FAMILY CHILD CARE
FACILITY NUMBER: 197418849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observed LIC 9227 in the children (Infant's) file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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The licensee agreed to submit the LIC 9227 by Next Friday.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
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