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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426211932
Report Date: 06/15/2022
Date Signed: 06/15/2022 03:01:04 PM


Document Has Been Signed on 06/15/2022 03:01 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:BERNAL FAMILY CHILD CAREFACILITY NUMBER:
426211932
ADMINISTRATOR:TOMASA BERNALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 562-8124
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:14CENSUS: 6DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tomas BernalTIME COMPLETED:
03:20 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 6/15/2022, at 11:30 PM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection. LPA met with Tomas Bernal, Licensee and Maria Bernal, Co-licensee. The purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed three (3) infant and three (3) children in care at the time of the inspection.

The main day care areas are living room, kitchen, dining room, napping room and hallway bathroom. LPA observed the children's bathroom to be 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 two (2) bedrooms, one (1) bathroom, and detached garage, which are secured with safety gates, door knob covers and safety locks on the doors making the off limit areas inaccessible to children. The backyard is completely fenced. LPA observed age appropriate toys, and, play structure in the backyard. LPA observed two (2) small outdoor dog

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. LPA reviewed children's files, which revealed child #3 and child #4 did not have a Safe Sleep Plan (LIC 9227) and Safe Sleep Chart. The fire extinguisher was observed and was serviced June 15, 2021. The carbon monoxide detector and smoke alarm that were tested and functioning at 12:31 PM, that meets statutory requirements. Licensee is current with immunization required per SB 792. The last Safety drill was conducted on January 18, 2022. Licensee is current with CPR and First Aid which expires September 22, 2022. Licensee completed the Mandated Reporter Training required per AB 1207, on September 21, 2018.

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: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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 4


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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 426211932
VISIT DATE: 06/15/2022
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), What is Carbon Monoxide?, and The Effect of Lead. 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, deficiency cited under Title 22 Division 12 Appeal rights given. THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. LPA observed the "Notice of Site Visit" posted. 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: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/15/2022 03:01 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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 426211932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee stated she was unaware of the safe sleep log and has not documented labored breathing, signs of distress, body temperatures, or checking on them every 15 minutes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee will check and document the observation of infant every 15 minutes while infant is sleeping and provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/21/2022

Martina.Jimenez@dss.ca.gov
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 observation, interviews, and record reviewed, the licensee did not comply with the section cited above. Licensee stated licensee and co-licensee had completed the mandated reporter training on September 21, 2018. Licensee stated was not aware that the mandated reporter training is to be renewed every two years, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee will submit photos of mandated reporter training certificates and written statement on how licensee will prevent future incidents to LPA by POC due by 6/22/2022.

Martina.Jimenez@dss.ca.gov

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: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/15/2022 03:01 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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 426211932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of file and interview, the licensee did not comply with the section cited above Child # 3 & child #4 do not have Individual Safe Sleep Plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee agreed to discuss with parent the Safe Sleep plan and obtain the signature. Licensee to will submit provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/22/2022.

Martina.Jimenez@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee stated she was unaware of the safe sleep log and has not documented labored breathing, signs of distress, body temperatures, or checking on them every 15 minutes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee will check and document the observation of infant every 15 minutes while infant is sleeping and provide proof of photos and written statement on how licensee will prevent future incidents to LPA by POC due by 6/22/2022

Martina.Jimenez@dss.ca.gov

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: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4