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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426214393
Report Date: 08/16/2024
Date Signed: 08/16/2024 10:50:47 AM


Document Has Been Signed on 08/16/2024 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:WILSON FAMILY CHILD CAREFACILITY NUMBER:
426214393
ADMINISTRATOR:LUCIA J. WILSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 717-9529
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 1DATE:
08/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lucia J WilsonTIME COMPLETED:
11:00 AM
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On 08/16/2024 Licensing Program Analysts (LPAs) German Negrete and Sylvia Ceja conducted an unannounced case management inspection and met with Licensee Lucia J. Wilson. The purpose of the inspection is to deliver a exemption of denial letter/notice for individual#1. And to obtain a conformation of removal (COR) for individual#1 to ensure Individual #1 is not present at the facility. At 9:30AM LPAs observed one infant(grandchild) present under the care of Licensee.

During today’s inspection, LPAs accompanied by Licensee toured the entire home, LPAs did not observe Individual #1 and their belongings on the property. Per Licensee, Individual #1 does not reside or work at the facility. Licensee completed and signed the Confirmation of Removal for Individual #1 (LIC 300B). Licensee is informed she is required to notify parents of children in care that this individual has been removed from the home. Licensee was also provided the Family Child Care Home Addendum to Notification of Parents' Rights (LIC995B) which needs to be completed by all parents.

Verification of removal is complete.

Continued on LIC809-C

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 218-0429
LICENSING EVALUATOR NAME: German NegreteTELEPHONE: 805-315-8362
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WILSON FAMILY CHILD CARE
FACILITY NUMBER: 426214393
VISIT DATE: 08/16/2024
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Licensee has to a copy of the Addendum To Notification of Parent's Rights (LIC 995B) for each child in care. Licensee issued a declaration (LIC 855) stating that the Individual no longer resides in the home.

Exit interview conducted and report was reviewed with Licensee, Wilson.



Notice of Site Visit was issued. The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Copies of this report must be posted for 30 days in a visible location for the authorized representatives of children.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 218-0429
LICENSING EVALUATOR NAME: German NegreteTELEPHONE: 805-315-8362
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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