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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421711005
Report Date: 10/21/2019
Date Signed: 10/21/2019 03:33:36 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:PICO FCC AKA DORIS FAMILY CAREFACILITY NUMBER:
421711005
ADMINISTRATOR:PICO, DORISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 736-7468
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 7DATE:
10/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Doris Pico and GabrielleTIME COMPLETED:
03:40 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
An annual random was conducted by Licensing Program Analysts (LPAs) S. Mendoza-Ceja and B. Cervantes who met with Licensee's Assistant Gabrielle Corral. Licensee Doris Pico arrived within approximately 10 minutes. The home was toured inside and outside. Licensee stated there are no firearms, ammunition or bodies of water on the premises. LPAs did not observe any bodies of water. The fire place was observed to be screened. The 2 A10BC Fire Extinguisher was serviced on 07/12/2018 (gauge was observed to be in the green) was serviced on 07/12/2018. LPA advised the licensee the Fire Extinguisher needs to be serviced or replaced yearly. There is a dual smoke/carbon monoxide detector in the hallway.
The children’s records were reviewed for emergency information. LPAs reviewed “Safe Sleep in Child Care, Safe Sleep for your Baby, and Effects of Lead Exposure” and provided handouts. Licensee and assistant Gabrielle Corral both have current CPR and First Aid is current (expires 06/28/2020). LPA discussed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, and Measles. Verification on file. LPAs verification AB 1207 Child Abuse Mandated Reporter Training completed for Licensee Doris Pico and her assistant Gabrielle Corral.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
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: PICO FCC AKA DORIS FAMILY CARE
FACILITY NUMBER: 421711005
VISIT DATE: 10/21/2019
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
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

The following Type B deficiency is cited according to CCR, Title 22, Division 12. Appeal Rights reviewed. The Notice of Site Visit was posted at the visit.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2019
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: PICO FCC AKA DORIS FAMILY CARE
FACILITY NUMBER: 421711005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2019
Section Cited

1
2
3
4
5
6
7
Operation of a FCCH; The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: ... The home shall contain a fire extinguisher...hich meet standards established by the State Fire Marshal.
8
9
10
11
12
13
14
The above regulation was not met as evidenced by the licensee's failure to service or replace the 2 A10 BC Fire Extinguisher yearly as required, last service was 07/12/2018. This poses a potentioal Health, Safety or Personal Rights risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3