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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215943
Report Date: 06/11/2020
Date Signed: 06/12/2020 08:25:17 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:PEREZ FCC AKA MAYA'S CAREFACILITY NUMBER:
406215943
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
06/11/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelica PerezTIME COMPLETED:
05:13 PM
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On June 11, 2020 @ 2:39 PM, Licensing Program Analyst (LPA) Martina Jimenez conducted an announced Tele- Inspection for the purpose of performing a pre-licensing inspection. Due to the COVID - 19 and California Department of Public Health guidelines of social distancing, a tele-inspection was conducted. LPA Jimenez conducted the tele-inspection via Face-Time and met with Angelica Perez, Applicant and discussed the purpose of the Inspection.

LPA Jimenez with the assistance of the applicant conducted a virtual tour of the interior and exterior of the home. The home is a 5 bedroom, 2 bath single story home with an attached garage. All adults in the home are fingerprint cleared. LPA observed the off-limits areas which includes the bedrooms and garage secured with locks, and doorknob covers. The fireplace which is located in the living room has glass doors and will not be used. The main day-care areas are the kitchen. dining room, living room, day-care room and hallway bathroom. LPA observed the home to be orderly. The bathroom used by children was observed to be clean and free of toxins. All hazardous items are stored inaccessible to children in care. Medication and sharps in the home are stored on elevated shelves in the kitchen's cabinets. LPA observed clean, safe, age appropriate toys. LPA observed the outdoor play area completely fenced. LPA observed age appropriate toys, bikes, bike area, shade area and grass area.

No bodies of water were observed on site at the time of the visit. The smoke alarm detector affixed to the hallway which was tested at 4:07 PM and found to be operable. LPA reminded the Applicant Family Child Care Homes (FCCH) must maintain operable carbon monoxide and smoke alarm detector at all times. LPA observed a fire extinguisher on site which was last serviced on 5/20/19. Applicant is reminded to service or purchase the fire extinguisher yearly.

The applicant completed Preventative Health training on 03/07/20. Applicant’s Pediatric CPR and First Aid certificate expires on 02/29/20. Applicant informed LPA no firearm or ammunition is stored on site. Applicant does not have a foster care license. CONTINUED ON 809-C

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PEREZ FCC AKA MAYA'S CARE
FACILITY NUMBER: 406215943
VISIT DATE: 06/11/2020
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LPA reviewed mortgage statement to verify control of property. Applicant states the FCCH does not currently have liability insurance. LPA informed applicant that parents will need to sign a waiver for the liability insurance if insurance is not obtained (applicant was provided form- LIC 282). The Applicant completed AB 1207 Mandated Reporter training on 06/10/20. Applicant is current with immunization requirements per SB 792. Applicant completed the FCCH orientation on 2/10/20.


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


LPA issued the applicant updated samples of state required forms to be kept in the children's records via Email. LPA discussed AB 633 with applicant as well as packet of updated samples of state required forms to be kept in the children's file, required forms to be posted and forms that needs to be maintained at the FCCH. LPA also discussed and provided information about the Effects of Lead, Sudden Infant Death Syndrome/Safe sleep, and Capacity requirements.

Applicant was reminded that it is her responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov. Also, applicant was reminded that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours.



Exit interview was conducted with Angelica Perez Applicant via tele-inspection. This report along with a copy of the Notice of Site Visit will be sent to the Applicant via email with a read receipt or confirmation of receipt of email, which will act as the Applicants signature. Applicant must sign and return a copy of this pre-licensing report. The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez.

THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. The home will be Licensed once Applicant submits verification of the following:

1. Carbon Monoxide Detector


2. Fire Extinguisher receipt/purchase
3. Applicant is to make the following items in the backyard areas inaccessible to children; 2- ladder

License is pending the above corrections
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
LIC809 (FAS) - (06/04)
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