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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406212946
Report Date: 10/08/2019
Date Signed: 10/09/2019 08:51:13 AM

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:SILVA FCC AKA KIDS IN ACTIONFACILITY NUMBER:
406212946
ADMINISTRATOR:MARICELA SILVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 929-3503
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:14CENSUS: 11DATE:
10/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Maricela SilvaTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Gigi Reyes and Eric Lin conducted an unannounced annual/random and met with Licensee and Assistant. There were 11 children present. The home was toured inside and out. The home is situated in a one acre property. This is a one story home with 4 bedrooms, one bedroom adjacent to children's playroom is used by day care children. Kitchen is inaccessible to children. The garage converted to day care is used for indoor day care activities. An enclosed outdoor activity space is located in the front house. The backyard is not accessible to children in care. LPAs observed age appropriate toys and equipment. Cleaning supplies, hazardous items are kept inaccessible to children in care. There were no bodies of water observed. Licensee stated there is no gun or ammunition in the home.

Fire extinguisher was last serviced on 1/20/2019, Carbon monoxide and smoke detectors were present and functional. CPR and First Aid expires on 4/27/2021. Home has current children's roster. Licensee and Assistant do not have complete record of immunization on file. LPAs reviewed Children's files, Child # 1's Immunization card is not updated. LPAs discussed the Safe Sleep Concept and Best Practices and provided flyers. "The Effects of Lead Exposure" was discussed, flyers were provided for distribution to parent in day care.

Continued on 809 C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019
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: SILVA FCC AKA KIDS IN ACTION
FACILITY NUMBER: 406212946
VISIT DATE: 10/08/2019
NARRATIVE
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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: http://www.ada.gov/childqanda.htm

In the areas evaluated, deficiencies cited under Title 22 Division 12 and Health and Safety Code (809 D)



Appeal Rights Given.

LPA observed Licensee posted the Notice of Site Visit.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019
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: SILVA FCC AKA KIDS IN ACTION
FACILITY NUMBER: 406212946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2019
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each
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This requirement is not met as evidenced by: Based on review of Staff records, it was observed that Licensee's and Assitant's immunization record are not complete. This poses a potential risk to health and safety of children in care.
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Type B
10/18/2019
Section Cited

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(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
(1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
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This requirement is not met as evidenced by: LPAs' review of children's files revealed that Child # 1 's PM 286 is not updated. This poses a potential risk to health and safety of children in care.
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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: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3