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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216030
Report Date: 11/25/2020
Date Signed: 11/25/2020 02:34:36 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:CAZARES FAMILY CHILD CAREFACILITY NUMBER:
406216030
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
11/25/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Rocio CazaresTIME COMPLETED:
12:38 PM
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On November 25, 2020 @ 8:57 AM, Licensing Program Analyst (LPA) Francisca Velazquez 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 asked Applicant Pre- Screening questions related to COVID-19. Applicant's responses to the Pre-screening questions suggest no COVID-19 exposure on site. LPA Velazquez conducted the tele-inspection via face-time and met with Rocio Cazares, Applicant and discussed the purpose of the Inspection in Spanish.

LPA Velazquez with the assistance of the Applicant conducted a virtual tour of the interior and exterior of the home. This is a mobile home consisting of three (3) bedrooms, one (1) bathroom, living room, kitchen and small fenced patio by the front door. All adults in the home are fingerprint cleared.

During this tour the following was noted:

Applicant applied for a Small Family Child Care license. Family members residing in the home are Applicant, Applicant’s spouse, and three (3) children ages 9, 13, 17. Per Applicant, the operating hours will be Monday through Saturday from 5:00 AM to 6:00 PM. Applicant states she wants to care for children from birth to 12 years of age.

All areas identified on the facility sketch were inspected. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation. LPA Velazquez observed small outdoor front patio completely fenced. There are no bodies of water observed in the home. Applicant stated the mobile park has a pool in their complex that can only be open with a key from management. Applicant stated she will not be using the pool at all. Mobile park also has small play area that Applicant plans to use weather permitting and with enough supervision to allow children to run around. CONT. 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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: CAZARES FAMILY CHILD CARE
FACILITY NUMBER: 406216030
VISIT DATE: 11/25/2020
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Off limit areas included: All three (3) bedrooms were observed to have locks requiring a key to be able to open the bedroom.
Areas used by children included: living room, kitchen, hallway bathroom and small fenced patio.

LPA Velazquez observed some COVID-19 related posters in the drop-off/pick-up area for parents and children posters around the living room. LPA Velazquez will email self-assessment for completion and more resources for Applicant to have.

LPA Velazquez observed all areas to be used by children to be safe and free to toxins. In the kitchen, LPA Velazquez observed all cabinets with safety latches, cleaning materials stored in high cabinet with extra safety latch, and knives stored in high cabinet with safety latch. Bathroom was clean and all cabinets had safety latches making them inaccessible to children. Bathroom has hand washing visuals and proper soap and towels for hand washing.

The Applicant states that she will participate in the food program through her local Resource and Referral office to provide food for children in care. There are age appropriate toys and napping equipment on the premises.

The required fire extinguisher 2A10BC was purchased on October 13, 2020. At 9:50 AM, LPA Velazquez tested smoke and carbon monoxide detector at the time of the visit and found them to be working. Per Applicant, there are no guns and ammunition in the home. First Aid and emergency kits are available.

The Applicant completed the Orientation on April 11, 2020. The Applicant has current Pediatric First Aid and CPR expiring August 21. 2022. Applicant completed the Mandated Reporter Training on August 30, 2020. The Applicant completed Preventative Health Certificate including Lead training on August 20, 2020. Applicant has proof of immunization per SB 792 against influenza, pertussis, and measles.

The following was discussed with the applicant:


- Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

CONT 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: CAZARES FAMILY CHILD CARE
FACILITY NUMBER: 406216030
VISIT DATE: 11/25/2020
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- In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization's, and a valid criminal record clearance associated to the facility license.
- A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.
-The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
- Changes in the home should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if applicant moved to another location/ home.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements were reviewed and explained.

- Fire and safety drills must be performed every six months and documented for review by the Department.

- Smoking is prohibited in a Family Child Care Home, 24/7.


- Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
- All adults living and working in the home shall be made of aware of the Department inspection rights authority.

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



No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. CONT 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: CAZARES FAMILY CHILD CARE
FACILITY NUMBER: 406216030
VISIT DATE: 11/25/2020
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During this visit, the LPA Velazquez reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the applicant. LPA Velazquez advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

LPA discussed with the applicant Safe Sleep Regulation, (PIN 20-24).

· Infant up to 12 months of age must be on their backs to sleep, unless there is a medical exemption from a licensed physician that allows for an alternative sleeping position.


· Cribs must be free from all loose articles and objects, including blankets and pillows.
· Mattress must be firm and include a tight fitted sheet.
· infants must not be forced to sleep, stay awake, or stay in the sleeping area.
· Infants must not be swaddled while in care.
· An infant's head must not be covered while sleeping.
· If an infant falls asleep before being placed in a crib, for example, in a provider's arms or stroller, the provider must move the infant to a crib (or play yard for FCCHs) as soon as possible.
· Car seats will only be used for transportation and must not be used for sleeping within a childcare facility.
· All pacifiers cannot have anything attached, such as a stuffed animal or a clip meant to attach the pacifier to the infant's clothing.
· Providers must check on sleeping infants every 15 minutes and document their condition to check for signs of distress, which includes, but is not limited to labored breathing, flushed skin color, increase in body temperature, and restlessness.
· Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

LPA also advised against sleeping infants in a separate room.

CONT. 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CAZARES FAMILY CHILD CARE
FACILITY NUMBER: 406216030
VISIT DATE: 11/25/2020
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Forms to be posted
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License

Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse,
Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).

Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights



Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

This home meets all the requirements for a Small FCCH license. License is effective today November 25, 2020.

Exit interview was conducted with Rocio Cazares, Applicant, via tele-inspection. This report 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. In addition, LPA Velazquez will also mail out a copy of report for Applicant to sign and mail back to our office.


There were no deficiencies cites at this time. 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: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC809 (FAS) - (06/04)
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