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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426209899
Report Date: 06/25/2019
Date Signed: 06/25/2019 12:18:55 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:FLORES FCC AKA SILVIA'S DAYCAREFACILITY NUMBER:
426209899
ADMINISTRATOR:SILVIA FLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 733-5272
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 14DATE:
06/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Silvia FloresTIME COMPLETED:
12:30 PM
NARRATIVE
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An annual random was conducted by LPA S. Mendoza-Ceja who met with Licensee Silvia Flores and her husband Octavio Flores who were providing care to 14 children. The home was toured inside and outside. Licensee stated there are no firearms, ammunition or bodies of water on the premises. LPA did not observe any bodies of water. The fire extinguisher was serviced on 10/25/2018. Licensee is reminded to service or replace the 2A10BC Fire Extinguisher yearly. There is a smoke detector and carbon monoxide detector in the home which were tested. The child care roster was reviewed. LPA reviewed and provided copy of the handouts “A Child Care Provider’s Guide to Safe to Sleep, Safe Sleep in Child Care, Effects of Lead Exposure”. The last emergency drill was conducted on 02/07/2019. Licensee Silvia Flores and Octavio Flores both have current CPR and First Aid (expires 02/21/2021).

LPA reviewed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, and Measles. LPA also advised, each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year or obtain a sign statement declining the influenza vaccination. Review of records revealed verification of immunization were missing for one adult. LPA also reviewed the requirement for the AB 1207 Child Mandated Reporter Training.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2019
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: FLORES FCC AKA SILVIA'S DAYCARE
FACILITY NUMBER: 426209899
VISIT DATE: 06/25/2019
NARRATIVE
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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 in regards to immunization records.
Appeal Rights reviewed.

Report was translated by Octavio Flores in Spanish.

The "Notice of Site Visit" was posted at the visit.

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: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2019
LIC809 (FAS) - (06/04)
Page: 3 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: FLORES FCC AKA SILVIA'S DAYCARE
FACILITY NUMBER: 426209899
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2019
Section Cited
HSC
1597.622(a)(1)
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Health and Safety - Employees or volunteers at family day care home; immunization requirements; records; exemptions: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Please submit verification to LIcensing for review by July 16, 2019.
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This requirement was not met as evidenced by the record review and interview which revealed Licensee did not have verification of MMR, and Tdap for one volunteer which poses a potential health and safety risk to children 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: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2019
LIC809 (FAS) - (06/04)
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