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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426205523
Report Date: 01/08/2020
Date Signed: 01/08/2020 10:31:14 AM

COMPREHENSIVE INSPECTION
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:BORNEMAN FAMILY CHILD CAREFACILITY NUMBER:
426205523
ADMINISTRATOR:TRACEY ANN BORNEMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 937-1680
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 6DATE:
01/08/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Robyn VelasquezTIME COMPLETED:
10:25 AM
NARRATIVE
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On January 8, 2020, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced Required Annual inspection of the abovementioned Family Child Care Home (FCCH). LPA met with Robyn Velasquez, Assistant of the FCCH and explained the purpose of the inspection. Assistant informed LPA the Licensee, Tracey Borneman, was off site at the time of the inspections. LPA, in the company of the Assistant, toured the interior and exterior of the FCCH. The FCCH's living room, backyard and hallway restroom are used for child care, while the home’s bedrooms, garage and detached "grandmother quarters" are excluded from child care. At the time of the inspection six children are present.

Required licensing forms and documents are posted in the FCCH. The FCCH's living room has a fireplace which is screened by a metal mesh cover. LPA observed a combination smoke and carbon monoxide detector which was tested and found to be operable. LPA observed a regulation fire extinguisher which was service on September 12, 2019. LPA reminded Assistant to either service or purchase a regulation fire extinguisher annually.

The backyard is enclosed by wooden and brick fencing. There are numerous sheds in the backyard area which contain gardening and outdoor equipment/furniture. All sheds observed were secured with locks. Toys and play equipment observed in backyard were varied and age appropriate. No bodies of water were observed on site.

The home was clean and orderly. LPA observed no hazardous items on site. Medication is stored in a kitchen cabinet on an elevated shelf. Medication is also stored in the master bedroom. Both area are excluded from care and inaccessible to children. Cleaning compounds are stored in the FCCH's garage which is an area excluded from care and inaccessible to children . Toys, furniture and equipment observed in the FCCH's living room were age appropriate.
CONT. 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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: BORNEMAN FAMILY CHILD CARE
FACILITY NUMBER: 426205523
VISIT DATE: 01/08/2020
NARRATIVE
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LPA reviewed children records. The records were current, complete and possessed emergency contact information as mandated by regulations. The Assistant's CPR and First Aid certifications are current and expire on April 7, 2020. Assistant had no Mandated Reporter Training Certificate for inspection. LPA reminded the Assistant of responsibility to complete Mandated Reporter training.

The Assistant stated firearms and ammunition are stored on site. The firearms and ammunition are stored in a safe at the FCCH which is inaccessible to the Assistant and children.

The Licensee is not providing Incidental Medical Services (IMS). Policy was discussed. 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 Family Child Care Homes and the ADA, available at: www.ada.gov/childqanda.htm

LPA reviewed and provided Assistant with a copy of “Child Care Providers Guide to Safe Sleep." LPA reviewed and provided “Effects of Lead Exposure” to be distributed to all families. Assistant was reminded of responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D). The Assistant was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

The LIC9213 (Notice of Site Visit) was posted.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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: BORNEMAN FAMILY CHILD CARE
FACILITY NUMBER: 426205523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2020
Section Cited

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1596.8662(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...
following the date on which he or she completed the initial mandated reporter training.
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This requirement was not met as evidenced by: Based on interviews/records review/observations S#1 and S#2 did not have Mandated Reporter training certificates.

This poses a potential health and safety risk to persons 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: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2020
LIC809 (FAS) - (06/04)
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