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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406209024
Report Date: 01/13/2020
Date Signed: 01/13/2020 01:37:09 PM

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:HERNANDEZ FCC AKA BLANCA'S CHILD CAREFACILITY NUMBER:
406209024
ADMINISTRATOR:BLANCA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 474-9374
CITY:OCEANOSTATE: CAZIP CODE:
93445
CAPACITY:14CENSUS: 4DATE:
01/13/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Blanca HernandezTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Melissa Stewart, conducted an unannounced annual/random inspection and met with Licensee, Blanca Hernandez. The purpose of the inspection was explained and the home was toured inside and out. All required forms are posted in a prominent location. At the time of inspection, there were 4 children (two being infants) supervised by Licensee and an assistant.

The family child care home operates on the first floor and backyard of the home. LPA observed age appropriate toys, books and furnishings in the indoor activity area. The bathroom used by children was observed to be clean and free of toxins. Upstairs and downstairs bedrooms are off limits and made inaccessible by child safety gates. All hazardous items are stored inaccessible to children in care. Licensee stated there are no guns or ammunition in the home. Outdoors, LPA observed play kitchen, bikes and age appropriate toys. The backyard is completely fenced; there are no bodies of water.

The home is equipped with a carbon monoxide and smoke detector. LPA observed two (2) regulation fire extinguishers which were serviced on 2/22/19. Licensee was reminded to service or replace the fire extinguisher yearly. Licensee completes and documents emergency drills. The most recent drill was held on 11/19/19. Licensee is Pediatric CPR and first aid certified through 3/7/21. Licensee and assistants have met SB 792 immunization requirement. Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: HERNANDEZ FCC AKA BLANCA'S CHILD CARE
FACILITY NUMBER: 406209024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2020
Section Cited

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102419 Admission Procedures and Parental and Authorized Representative's 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 Parents’ Rights, LIC 995A....
This requirement is not met as evidenced by:
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Based on LPA observation of Child 1's file, Licensee failed to ensure that Child 1s file was complete. Parent's Rights (LIC 995) was not signed/detached from the bottom portion to be provided to the parent and the parent's signature was not present on the Consent of Medical Treatment form LIC627
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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 MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HERNANDEZ FCC AKA BLANCA'S CHILD CARE
FACILITY NUMBER: 406209024
VISIT DATE: 01/13/2020
NARRATIVE
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Facility roster and all four (4) children's records were reviewed. Two required documents were not signed by Child 1's parent.

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: www.ada.gov/childqanda.htm

LPA reviewed and provided Licensee with Safe to Sleep brochure in Spanish. LPA provided “Effects of Lead Exposure” brochure to be distributed to all families. 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) which can be accessed on-line at www.ccld.ca.gov.

See LIC 809-D for cited deficiency in accordance with the California Code Regulations Title 22, Division 12 and/or Health and Safety Code. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Blanca Hernandez, whose signature on this form confirm receipt of these documents.

LPA observed Licensee post the Notice of Site visit.



Spanish language translation of the inspection and this report were provided by Licensee's assistant.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3