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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215565
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:26:36 PM


Document Has Been Signed on 04/07/2022 01:26 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:CHACON FAMILY CHILD CAREFACILITY NUMBER:
426215565
ADMINISTRATOR:EDIS Y. CHACONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 636-3211
CITY:SANTA BARBARASTATE: CAZIP CODE:
93103
CAPACITY:14CENSUS: 9DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Edis ChaconTIME COMPLETED:
01:40 PM
NARRATIVE
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On April 7, 2022 at 11:06 AM Licensing Program Analysts (LPA) Austin Rios and (LPA) Rona Chavez conducted an unannounced annual inspection. LPAs met with licensee Edis Chacon and discussed the nature and purpose of the inspection. Together both licensee and LPA conducted a tour of the home inside and outside. There was nine children in care at the time of the inspection.

The licensee uses the living room, one bedroom, one restroom, and backyard for the day-care. There are no bodies of water in the home. Licensee states that there are no firearms and ammunition in the home. LPA did not observe toxins/hazards accessible to children in care. In the family room. There are age appropriate toys and furniture readily accessible to children. The backyard is fully enclosed with a fenced wall. Licensee has a shed in the backyard with a lock on it. Licensee has age appropriate toys and play structures in the backyard in good condition and free of hazards. LPA observed there was ample amount of shade available for children.

The home has a working smoke and carbon monoxide detector. A 2A10BC fire extinguisher was observed in the kitchen with a purchase date of 2/18/2022. Licensee has a valid Pediatric CPR/First Aid certificate with an expiration date of . Licensee has AB 1207 Mandated Reporter Training Certificate on file expiring on 7/11/2022. The last fire drill was conducted on 4/7/2022. All required forms are prominently posted for parent's or authorized representatives to view at the entrance.

Licensee did not have current CPR card on file. California Code of Regulation, (Title 22 Division 12 and 102416(c) type B deficiency is being cited on the attached LIC 809 D). Facility is also being given a type B for not having signed parent rights in children's files Title 22 division 12 102419(d)(1) and 102421(b) for not having emergency contact information in the children's files.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin RiosTELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
VISIT DATE: 04/07/2022
NARRATIVE
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A roster of children in care was observed current and complete. A sampling of children's records were reviewed and found incomplete.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) 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 IMA 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin RiosTELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/07/2022 01:26 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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee will submit proof of CPR card by 4/21/2022 to LPA Rios at 805 635-4725 or austin.rios@dss.ca.gov
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee will submit proof of emergency information card and contact information for the children by 4/21/2022 to LPA Rios at 805 635-4725 or austin.rios@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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin RiosTELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/07/2022 01:26 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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care 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 (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review)], the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee will submit proof signed parent rights by 4/21/2022 to LPA Rios at 805 635-4725 or austin.rios@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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin RiosTELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


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: 04/07/2022
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Edis Chacon.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin RiosTELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5