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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215565
Report Date: 03/05/2020
Date Signed: 03/05/2020 04:49:25 PM

COMPREHENSIVE INSPECTION
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:CHACON FAMILY CHILD CAREFACILITY NUMBER:
426215565
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 7DATE:
03/05/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Edis ChaconTIME COMPLETED:
05:10 PM
NARRATIVE
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On March 5, 2020, Licensing Program Analyst (LPA) Sylvia Mendoza-Ceja conducted an unannounced Required 1 Year Inspection and met with Licensee, Edis Chacon. LPA discussed the purpose of the inspection and was granted entry into the facility. LPA observed Licensee Edis Chacon providing care to 7 children in the home.

11:08 AM, a parent arrived to pick up child #1. LPA reviewed the child care roster and did and reviewed children's records for additional information. It was found provider was providing care to five infants (children under the age of 2 years) and two children over the age of 2 years. Census was reduced to six children for up to 8 minutes. LPA advised Licensee Chacon she had too many infants/children in care. At 11:15 AM, LPA heard a child cry out in the bedroom. Licensee went into the bedroom and brought child #7 from the bedroom to the living room to be with the other children.

11:16 AM, another parent arrived and dropped off child #8. LPA now determined Licensee was now providing care to four infants (children under the age of 2) and 3 children (over the age of 2 years). LPA advised Licensee Chacon she had too many infants/children in care.

11:22 AM, LPA observed licensee pick up child #2 by the left arm. LPA advised, Licensee she cannot pick up a child in that manner. LPA discussed she could injure a child.

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

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
VISIT DATE: 03/05/2020
NARRATIVE
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At 11:50 AM, child #7 was picked up.

The home was toured inside and outside. The home was observed to be clean and orderly. The backyard fenced area was also observed to be appropriately furnished with toys. Licensee stated there are no firearms/ammunition or bodies of water on the premises. LPA did not observe any toxins accessible to children.

At 11:57 AM, child #4 was picked up.

At 12:01 PM, LPA tested smoke detector, carbon monoxide detector which were function. Then LPA inspected the 2 A10 BC Fire Extinguisher, however there was no receipt or service date documented. Licensee stated she purchased the fire extinguisher 6 months ago. Licensee Chacon stated she did not conduct the emergency drills. Further review of children's records and including the child care roster revealed the two of the children in care did not have files and the other six files were incomplete. LPA also found the child care roster was not current. LPA provided the handouts in Spanish "A Child Care Provider's Guide to Safe Sleep, Effects of Lead Exposure and Child Mandated Reporter Training" and discussed with Licensee Chacon. LPA discussed AB1207 Child Abuse Mandated Reporter Training with Licensee Chacon.". Licensee Chacon's CPR and First Aid expired on 02/17/2020.

12:10 PM, Child #2 was picked up.

LPA reviewed the requirement for care providers/employees and volunteers to obtain immunization against Influenza, Pertussis, and Measles. Verification was reviewed for Licensee.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
VISIT DATE: 03/05/2020
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation...Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation.



Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, refer to LIC809Ds. Deficiencies regarding staffing, ratio and capacity, personal rights, Pediatric CPR and First Aid, including children's records and other record keeping requirements were cited.

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee Chacon. A copy of this report and appeal rights were discussed and left with Licensee Chacon, whose signature is on this form to confirm receipt of these documents. Report Translated in Spanish by Language Link #1777.

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

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2020
Section Cited

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 Staffing, Ratio & Capacity: For a Small FCCH, the maximum number of children for whom care may be provided at any one time...shall be one of the following:(1)Four infants; or (2)Six children, no more than three of whom may be infants; or (3)More than six and up to eight children, without an additional adult attendant, only if the criteria in Section 1597.44 of the Health and Safety Code are met.
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This requirement was not met as evidenced by: Based on observation, interview, and record review which revealed licensee Chacon was providing care for seven (7) children at one time of which up to five (5) were observed to be infants, none of the children in care were school age. Thia poses an immediate Health, Safety, or Personal Rights risk to children in care
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Type A
03/05/2020
Section Cited

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102423(a)(2) Personal Rights (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.



This requirement was not met as evidenced by:
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Based on observation and record review Licensee was observed picking up child #2 by the left arm which poses an immediate 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: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2020
Section Cited

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Operation of a FCCH (g)...Safety precautions shall include but not be limited to: (1) ...The home shall contain a fire extinguisher,...which meet standards established by the State Fire Marshal.

This requirement was not met as evidenced by:
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Based on observation, interview, and record review revealed the Licensee did not have verification of the purchase or service date for the 2 A10 BC Fire Extinguisher. This poses a potential health and safety risk to children in care.
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Type B
03/09/2020
Section Cited

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Operation of a FCCH(g)...Safety precautions shall include but not be limited to:(9) Each family child care home shall...(A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1.The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.
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This requirement was not met as evidenced by: Based on observation and interview, and record review revealed Licensee Chacon who stated she did not conduct the emergency drills.
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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: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2020
Section Cited

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 Operation of a FCCH: (7) ....the parent's authorization for the licensee or registrant to consent to emergency medical care.



This reqirement was not met as evidenced by:
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Based on observation, interview, and record review revealed the Licensee did not have Consent for Medical Treatment (LIC627) on file for the 8 chidren in care today. This poses a potential risk to health and safety of children in care.
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Type B
03/09/2020
Section Cited

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Operation of a FCCH: (m) (3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
This requirement was not met as evidenced by:
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Based on observation, interview, and record review revealed the Licensee did not have signed Affidavit Regarding Liability INsurance forms signed by parents of the 8 children in care. This poses a potential risk to health and safety of 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: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2020
Section Cited

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Admission Procedures and Parental and Authorized Representative's Rights:(d) At the time of acceptance... the licensee shall provide the child's parent... with a copy of the notice FCCCH Notification of Parents’ Rights, LIC 995A, the Caregiver Background Check Prcess Process, LIC 995E, and FCC Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept
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in the child’s file as proof...his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05)..... This requirement was not met as evidenced by: Based on record review and interview which revealed Parents Rights LIC 995A missing from 8 children's files. This is a potential risk to the health and safety of children in care.
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Type B
03/09/2020
Section Cited

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Operation of a FCCH; (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.


This requirement was not met as evidenced by:
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Based on record review and interview which revealed the child care roster was not current with all the children in care. Two of the children that were not listed did not have have any documents on file. This is a potential risk to the health and safety of 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: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
Page: 7 of 7