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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215687
Report Date: 09/21/2021
Date Signed: 09/21/2021 09:23:32 PM

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:LOPEZ FAMILY CHILD CAREFACILITY NUMBER:
426215687
ADMINISTRATOR:CARMEN LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 403-5053
CITY:BUELLTONSTATE: CAZIP CODE:
93427
CAPACITY:14CENSUS: 5DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Carmen LopezTIME COMPLETED:
02:30 PM
NARRATIVE
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On 9/21/2021 @ 12:20 PM Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced annual required inspection. LPA asked Licensee of pre- screening questions related to COVID-19, Licensee's responses suggest no COVID-19 exposure on site. LPA met with Licensee and discussed the purpose of the inspection. There were 5 children present, 1 of whom was an infant.

LPA toured the interior and exterior of the day care. Home is one story composed of 3 bedrooms and 2 1/2 baths. Converted garage is used by day care. LPA observed smoke and carbon monoxide detectors in the FCCH. The regulation fire extinguisher was purchased on 9/21/2021. The bathroom was inspected and observed to be clean and free of toxin. LPA observed the day care is clean and free of hazardous items. Licensee stated she conducts fire and disaster drill every 6 months but the drills were not documented.

During the inspection LPA observed that required licensing forms were not posted, License, Notice of Parent's Rights Poster and Emergency Disaster Plan.

The backyard is enclosed by wooden fence. LPA observed age appropriate toys and play equipment. No bodies of water were observed on site. Licensee stated guns and ammunition are stored separately in the vault.

Continued on LIC 809 C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215687
VISIT DATE: 09/21/2021
NARRATIVE
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LPA Reyes reviewed facility file and found complete, Pediatiric CPR and First Aid expires on 2/27/2023. AB 1207 Mandated Reporter Training was taken on 9/12/2020. Licensee was reminded that Mandated Reporter Training should be renewed every two years. Children's files were reviewed. LIC 9227 Individual Sleeping Plan form was completely filled out and signed by parents. Licensee checks on sleeping infants (0 to 24) every 15 minutes and documents it.

LPA discussed the COVID 19 Mitigation Plan. LPA discussed Safe Sleep Regulations with Licensee. Providers must check on sleeping infants (0 to 24 months) every 15 minutes and document their condition. Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

The Licensee is not providing 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: www.ada.gov/childqanda.htm

In the areas evaluated, deficiencies were cited under Title 22 Division 12 and Health and Safety Code. Deficiencies are documented on LIC 809 D. Appeal Rights were provided and explained.

Exit interview conducted with Licensee. Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 3 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited

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Operations of Family Child Care Home
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.
This requirement is not met as evidenced by:
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LPA review of facility record and statement from Licensee revealed that Licensee conducts fire and disaster drill every 6 months but she was not documenting it. This poses a potential risk to health and safety of children in care.
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Type B
09/21/2021
Section Cited

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Posting of License
A licensed child day care facility shall post its license in a prominent, publicly accessible location in the facility. A family day care home shall comply with this posting requirement during the hours when clients are present.
This requirement is not met as evidenced by:
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During the tour LPA observed that required forms are not posted in the FCCH including the License. Licensee stated she did not receive the new License when she applied for Large FCCH. 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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 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: LOPEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited

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Admission Procedures and Parental and Authorized Representative's Rights
The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.
This requirement is not met as evidenced by:
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During the inspection , LPA observed that PUB 394 was not posted. This poses a potential risk to health and safety of children in care.
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Type B
10/01/2021
Section Cited

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Operations of FCCH
Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department....
This requirement is not met as evidenced by:
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During the inspection, LPA observed that LIC 610 A Disaster Plan was not posted. 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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4