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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700071
Report Date: 01/03/2023
Date Signed: 01/03/2023 01:39:37 PM

Document Has Been Signed on 01/03/2023 01:39 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:SOBA FAMILY CHILD CAREFACILITY NUMBER:
197700071
ADMINISTRATOR:SOBA, NUBIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
6617238443
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Nubia, SobaTIME COMPLETED:
01:50 PM
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On 01/03/23 Licensing Program Analyst (LPA) Justeene Tamayo met with Licensee Nubia Soba, who guided analyst on a tour of the facility for the One Year Required inspection. This is a two story, 4 bedroom, 3 bathroom home with kitchen/dining, family room, living room, laundry room and garage. There is no pool/spa or body of water on the premises. Upon arrival LPA observed 4 infants, 4 preschool children, and 1 school age child in care, along with assistant #1. Family members residing in the home include 1 adult (licensee) and 3 minor children. Facility operation are Monday-Friday 8-4:30 PM. Incidental Medical Services (IMS) policy was discussed.

During initial walk through, LPA observed an uncleared adult #1 present in the home. Licensee is aware all adults 18 and over must be fingerprint cleared and associated before residing in the home and/or assisting with children.

The Facility has been cited a Type A deficiency according to the California Code of Regulations of Title 22 . Please see Facility Evaluation Report 809-D for deficiencies. A civil penalty of $500 has been assessed.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.
Mariela Ramon
Justeene Tamayo
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: SOBA FAMILY CHILD CARE
FACILITY NUMBER: 197700071
VISIT DATE: 01/03/2023
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Physical Plant: Main care is provided in the living room, family room, bedroom #1, and dining room area. Children use the bathroom in hallway on the right. Children have access to the living room, bedroom #1, family room, and dining room area. Off limit areas include bedrooms 2-4, office area, bathrooms #2 and #3 (upstairs), laundry room, and garage. LPA observed the main care area to be fully barricaded by a safety gate. The stairs were also barricaded. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen sink with safety latch), medicines (inside refrigerator on the top right side) and hazardous items (sharp knives on upper kitchen counter) that can pose a danger to children. LPA observed the kitchen area to be fully barricaded by a safety gate. LPA observed a fireplace in the the living room to be fully barricaded. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible. LPA reminded licensee, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment are allowed. There is a designated area for ill children as necessary in bedroom #1. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

Last Fire/Disaster Drill complete and maintained current. Last Fire/Disaster Drill was completed on 10/17/22.

Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPA did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.
SUPERVISOR'S NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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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: SOBA FAMILY CHILD CARE
FACILITY NUMBER: 197700071
VISIT DATE: 01/03/2023
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Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are under the kitchen sink with a safety latch. Licensee currently has a food program. Breakfast, lunch, snacks and dinner are provided. Naps are provided on cots in the family room area (classroom).

Outdoor: The backyard is safe for children. The backyard is completely fenced (with block cement). There is no body of water. There is an outdoor air conditioner barricaded by a wooden fence. LPA observed age appropriate toys. Both sides of the home are inaccessible to children with side gates. Per licensee, there are no pets on the premises.

Advisory/Other: First Aid kit was observed with supplies readily available. Assistant #1 CPR/First Aid expires 05/02/2024. Per licensee, she has registered on 12/19/22 to retake her CPR/First Aid class. Mandated Reporter expires 06/05/2024. There are no window cords accessible to children.

Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), and Emergency Disaster Plan. Licensee stated currently does not have child care insurance.

Licensee Soba 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.
SUPERVISOR'S NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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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: SOBA FAMILY CHILD CARE
FACILITY NUMBER: 197700071
VISIT DATE: 01/03/2023
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LPA discussed the safe sleep regulations with licensee Soba 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 licensee 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.

A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Nubia Soba along with her appeal rights.

SUPERVISOR'S NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2023 01:39 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 01/03/2023 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SOBA FAMILY CHILD CARE

FACILITY NUMBER: 197700071

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
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 or

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. LPA observed adult #1 present in the home without a fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2023
Plan of Correction
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Licensee is aware no adults shall reside or work in the home without a fingerprint clearance. Adult #1 is currently in process for a fingerprint clearance. Adult #1 shall not be present until the fingerprint clearance is granted by the Department of Justice.
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:Mariela Ramon
TELEPHONE:
LICENSING EVALUATOR NAME:Justeene Tamayo
TELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023


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