<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
426215720
Report Date:
01/16/2020
Date Signed:
02/06/2020 11:20:38 AM
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:
ROMERO FAMILY CHILD CARE
FACILITY NUMBER:
426215720
ADMINISTRATOR:
EVANGELINA ROMERO
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(805) 354-4742
CITY:
SANTA MARIA
STATE:
CA
ZIP CODE:
93454
CAPACITY:
14
CENSUS:
5
DATE:
01/16/2020
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
02:55 PM
MET WITH:
Evangelina Romero
TIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
THIS IS AN AMENDED REPORT.
This report was created under the incorrect facility number.
SUPERVISOR'S NAME:
Maria Mueller
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR NAME:
Martina Jimenez
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/16/2020
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
3
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:
ROMERO FAMILY CHILD CARE
FACILITY NUMBER:
426215720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2020
Section Cited
1
2
3
4
5
6
7
THIS IS AN AMENDED REPORT.
This report was created under the incorrect facility number.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Mueller
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR NAME:
Martina Jimenez
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/16/2020
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/16/2020
LIC809
(FAS) - (06/04)
Page:
2
of
3
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:
ROMERO FAMILY CHILD CARE
FACILITY NUMBER:
426215720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2020
Section Cited
1
2
3
4
5
6
7
THIS IS AN AMENDED REPORT.
This report was created under the incorrect facility number.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Mueller
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR NAME:
Martina Jimenez
TELEPHONE:
(805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE:
01/16/2020
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/16/2020
LIC809
(FAS) - (06/04)
Page:
3
of
3