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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210510
Report Date: 10/22/2020
Date Signed: 12/24/2021 10:54:42 AM

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:PEREZ FCC AKA LITTLE BLESSINGSFACILITY NUMBER:
426210510
ADMINISTRATOR:ANA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 588-7277
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 7DATE:
10/22/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Ana PerezTIME COMPLETED:
04:50 PM
NARRATIVE
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A Case Management Inspection was conducted by Licensing Program Analyst (LPA) S. Mendoza-Ceja who conducted an unannounced tele-inspection due to COVID - 19 State of Emergency. LPA met met with licensee Ana Perez following COVID-19 and Department of Public Health (DPH) guidelines of social distancing.

The purpose of the tele-inspection is to review the incident of July 27, 2020 when child #1 was bouncing aggressively in the My 1st Jump n Slide (bounce house) and jumped from one end of the bounce house to the other causing the bounce house to slide which resulted in child #1 hitting his head on an umbrella pole. Licensee stated she immediately provided first aid to child #1 and notified the parent. Child #1 did not require medical attention. Child #1 is not yet 3 years old and the bounce house was not anchored which poses a potential Health, Safety or Personal Rights risk to children in care.

Based on observation, interview, and record review: the Licensee failed to follow the manufacture directions of the "My 1st Jump n Slide" which indicates children shall be age 3 - 8 years and the product must be used with the anchors provided and installed properly.

The following Type B deficiency is cited according to CCR, Title 22, Division 12 in regards to Operation of a Family Child Care Home. Appeal Rights reviewed.

An exit interview was conducted with Licensee. This report will be sent to the Licensee via email with a read receipt for confirmation of receipt of the email, Licensee shall sign and return via email to LPA S. Mendoza-Ceja. Licensee shall post the "Notice of Site Visit for 30 days".

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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: PEREZ FCC AKA LITTLE BLESSINGS
FACILITY NUMBER: 426210510
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2020
Section Cited

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Operation of a Family Child Care Home. The home shall provide safe toys, play equipment and materials.

This requirement was not met as evidenced by the record review and interview with licensee:
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Licensee failed to provide safe toys and play equipment when she failed to follow the manufacturer’s directions of the "My 1st Jump n Slide" which revealed 1) the age range 3 years - 8 years and 2) the product must be used with anchors provided and installed properly. Child #1 was not yet 3 years old and the bounce house was not anchored. This poses a potential Health, Safety or Personal Rights 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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2020
LIC809 (FAS) - (06/04)
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