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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210691
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:54:19 PM


Document Has Been Signed on 06/21/2022 02:54 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:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
426210691
ADMINISTRATOR:ADRIANA HERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 928-9628
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:14CENSUS: 14DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Adriana HernandezTIME COMPLETED:
03:15 PM
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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 6/21/2022, at 11:25 PM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection. LPA met with Adriana Hernandez, Licensee, Jessica Hernandez, Assistant, and Laura Guzman, Assistant, the purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 13 children and 1 infant in care at the time of the inspection.

The main day care areas are living room, dining room, kitchen, day-care room, day-care room bathroom and hallway bathroom. 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 3 bedrooms and 1 bathrooms secured with doorknob covers and safety gate. The backyard is completely fenced. LPA observed age appropriate toys, bikes, play structure and playhouses.

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. Sampling of children's records were reviewed. The fire extinguisher was observed and was serviced July 20, 2021. There is a

This report continues on LIC 809C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 426210691
VISIT DATE: 06/21/2022
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functioning carbon monoxide detector and smoke alarm that were tested at 12:26 pm, that meets statutory requirements, were and functioning at the time of the visit. Licensee is current with immunization required per SB 792. The last Safety drill was conducted June 21, 2022. Licensee is current with CPR and First Aid which expires March 7, 2024. Licensee completed the Mandated Reporter Training on June 1, 2022, that is required per AB 1207.

Licensee is providing Incidental Medical Services. 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 Child Care Centers and the ADA, available at: htttp://www.ada.gov/childqanda.htm

LPA reviewed the handout "A Child Care Provider's Guide to Safe Sleep" (PIN 20-24-CCP), Effects of Lead Exposure, What is Carbon Monoxide. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided online at www.ccld.ca.gov.



The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez. There were no deficiencies cites at this time. LPA observed licensee post the Notice of Site 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: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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