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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426208062
Report Date: 06/30/2022
Date Signed: 06/30/2022 12:20:47 PM


Document Has Been Signed on 06/30/2022 12:20 PM - It Cannot Be Edited

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:CERVANTES FAMILY CHILD CAREFACILITY NUMBER:
426208062
ADMINISTRATOR:BLANCA CERVANTESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 343-1542
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY:14CENSUS: 7DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Blanca CervantesTIME COMPLETED:
12:35 PM
NARRATIVE
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 6/30/2022, at 9:15 AM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection of the home. LPA met with Blanca Cervantes, Licensee. The purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 7 children in care at the time of the inspection.

The main day care areas are living room, dining room, kitchen, day-care room, and hallway bathroom. LPA observed in the children's bathroom to be clean and free of toxins. LPA observed the day care area to be clean and orderly. LPA observed age appropriate books, toy, games, tables and chairs. LPA observed the off-limits areas which include the 4 bedrooms, 2 bathrooms and garage secured with doorknob covers on the doors making the off limit areas inaccessible to the children in care. The backyard is completely fenced. LPA observed in the backyard play area age appropriate toys, bikes, play structure, playhouses, shovel, pick fork rack, axs, and a metal hammer accessible to children in care. LPA observed a small outdoor dog secured in the garage. No bodies of water were observed.

Licensee stated that there are no weapons/ammunition in the home. Licensee stated she does not hold a foster family license. LPA reviewed the facility roster. The fire extinguisher was observed and was serviced November 10, 2021. There is a functioning carbon monoxide detector and smoke alarm that were tested at 10:03 am, in the home, that meets statutory requirements. Licensee is current with immunization required per SB 792. The last Safety drill was conducted and documented was on June 30, 2022. Licensee is current with CPR and First Aid which expires February 20, 2023. Licensee completed the Mandated Reporter Training on March 30, 2018, that is required per AB 1207.

THIS REPORT CONTINUES ON LIC 809C & LIC 809D
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 426208062
VISIT DATE: 06/30/2022
NARRATIVE
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Licensee is not providing Incidental Medical Services. 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: htttp://www.ada.gov/childqanda.htm

LPA reviewed with Licensee the Safe Sleep Regulation (PIN 20-24-CCP-SP), The Effects of Lead, and What is Carbon Monoxide. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided on line at www.ccld.ca.gov.

Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home and was advised to review Quarterly Updates and Provider Information Notices (PINs), Title 22 & Health & Safety Codes which can be accessed on-line athttps://www.cdss.ca.gov/inforesources/child-care-licensing

Today’s visit was conducted in Spanish.

Today, deficiency cited under Title 22 Division 12. Spanish Appeal rights were given.


Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report LIC 809 and LIC 809 D.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2022 12:20 PM - It Cannot Be Edited

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: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 426208062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observed in the backyard play area a shovel, pick fork rack, axs, and a metal hammer accessible to children in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee secured shovel, pick fork rack, axs, and a metal hammer during the inspection, making the garden tools inaccessible to children in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/30/2022 12:20 PM - It Cannot Be Edited

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: CERVANTES FAMILY CHILD CARE
FACILITY NUMBER: 426208062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, interview and record review, the licensee did not comply with the section cited above in the renewal of the mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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Licensee will submit via email a copy of the renewal of the mandated reporter training certificate to CCLD by July 7, 2022


Martina.Jimenez@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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