<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215081
Report Date: 09/07/2021
Date Signed: 09/07/2021 12:16:14 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:JIMENEZ FCC AKA LUPITA'S DAYCAREFACILITY NUMBER:
406215081
ADMINISTRATOR:IRMA JIMENEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 423-9289
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:14CENSUS: 4DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Irma JimenezTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/7/2021 at 11:00am, Licensing Program Analyst (LPA) Melissa Stewart conducted a Facility Risk Assessment for COVID19 with Licensee. All answers indicated no exposure to COVID19. The purpose of the visit, Required 1 year inspection, was explained. Licensee, Assistant and children over the age of two (2)years wore a face covering. LPA observed the required documents posted inside of the home on the wall adjacent to the front door. At time of inspection, LPA observed three (3) children in care. Assistant's mother (with criminal record clearance) was providing care to Assistant's five (5) week old infant in one of the bedrooms. Child care services are provided in the enclosed covered patio at the front of the home and indoors in the living room. LPA observed age appropriate furnishings, a variety of toys and books both indoors and outdoors. There is a crib inside and cots are stored in the closet. There are two (2) bedrooms which are not used for day care. The bathroom used by children was observed to be clean and free of toxins.

Licensee stated there are bodies of water and no guns or ammunition in the home. Detergents, cleaning compounds, medications and other items such as kitchen knives which could pose a danger to children are stored inaccessible to children. Combination smoke and carbon monoxide detector was tested at 11:10am and found to be operational. LPA observed the 2 A10 BC fire extinguisher with a service date of 4/23/2021. Licensee was reminded to service or replace the fire extinguisher yearly. Licensee completes and documents emergency drills every month. The most recent drill was held on 8/26/2021 at 1:28pm.

Facility roster and a sample of children's records were reviewed and found complete. Licensee and Assistant have current Pediatric CPR and first aid; Licensee's expires on on 6/20/22 and Assistant's expires on 7/17/2023. Licensee reported that Assistant had a test for tuberculosis (TB) on 8/24/2021 and that the result was negative, but that she does not have a record on file. Licensee has met SB 792 immunization requirement and completed Mandated Reporter Training per AB 1207 on 6/22/2021. Licensee stated that her Assistant started in June 2021 and completed the AB1207 training with her, but that she did not have a certificate of completion. 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: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
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 2
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: JIMENEZ FCC AKA LUPITA'S DAYCARE
FACILITY NUMBER: 406215081
VISIT DATE: 09/07/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA advised that all adults providing care to children must have a certificate of completion in their own name to be renewed every two (2) years.

Infant Safe Sleep Regulation section 102425 was discussed. LPA provided PIN 20-24-CCP, Individual Infant Sleep Plan (LIC9227) in English and Spanish and a sample Infant Sleep Log for 15 minute checks of all children under the age of two (2) years. LPA provided the “Effects of Lead Exposure” brochure to distributed to all families at time of enrollment. LPA advised Licensee that Title 22, Division 12 regulations for Family Child Care Homes and California Department of Public Health COVID-19 guidelines for child care programs can be accessed on-line at www.cdss.ca.gov. COVID19 Information for San Luis Obispo County can be found at https://www.emergencyslo.org/en/covid19.aspx. Licensee stated that she is subscribed to receive Provider Information Notices (PINs) from Community Care Licensing Division via email and that she also receives information and training for Community Action partnership of San Luis Obispo (CAPSLO.)

Incidental Medical Services (IMS) policy was discussed. Licensee stated that there are no children enrolled who require medications at this time. 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

In the areas evaluated today, no deficiencies were cited.

A copy of this report and appeal rights were discussed and left with Licensee, Irma Jimenez, whose signature on this form confirm receipt of these documents.

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2