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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215737
Report Date: 07/25/2022
Date Signed: 07/25/2022 04:58:52 PM


Document Has Been Signed on 07/25/2022 04:58 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:OLIVARES DE LIMON FAMILY CHILD CAREFACILITY NUMBER:
426215737
ADMINISTRATOR:LUCIA OLIVARES DE LIMONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 621-3735
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:14CENSUS: 5DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Lucia Olivares De LimonTIME COMPLETED:
05:15 PM
NARRATIVE
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 7/25/2022, at 2:42 PM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection. LPA met with Lucia Olivares De Limon, Licensee, the purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 3 children and 2 infant in care at the time of the inspection

The main day care areas are living room, dining room, kitchen, and hallway bathroom. LPA observed the day care area to be clean and orderly. LPA observed age appropriate books, toy, games, tables and chairs. LPA observed the off-limits areas which include the 4 bedrooms and 1 bathrooms secured with doorknob covers and safety gates. The backyard is completely fenced. LPA observed age appropriate toys, bikes, infant walker, play structure and playhouse.

No bodies of water were observed. Licensee stated that there are no weapons/ammunition in the home. Licensee stated she does not hold a foster family license. Sampling of children's records revealed infant #3 file does not have a safe sleep plan nor infant sleep chart. The fire extinguisher was observed and was serviced June 14, 2022. There is a functioning carbon monoxide detector and smoke alarm that meets statutory requirements, were tested at 2: 57 pm, and functioning at the time of the visit. Licensee is current with immunization required per SB 792. The last Safety drill was conducted April 18, 2022. Licensee is current with CPR and First Aid which expires December 14, 2022. Licensee completed the Mandated Reporter Training on December 12, 2020, that is required per AB 1207. This Report continues on LIC 809C and LIC 809D
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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: OLIVARES DE LIMON FAMILY CHILD CARE
FACILITY NUMBER: 426215737
VISIT DATE: 07/25/2022
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Licensee is not providing Incidental Medical Services. 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: htttp://www.ada.gov/childqanda.htm

LPA reviewed the handout "A Child Care Provider's Guide to Safe Sleep" (PIN 20-24-CCP-SP) What is Carbon Monoxide, and Effects of Lead Exposure. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided online at www.ccld.ca.gov.



The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez. Today, deficiency cited under Title 22 Division 12. Spanish Appeal rights were given. LPA observed licensee post the Notice of Site visit FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/25/2022 04:58 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: OLIVARES DE LIMON FAMILY CHILD CARE
FACILITY NUMBER: 426215737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, interview with licensee and record review, revealed infant #3 does not have a safe sleep plan,
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee will submit verification infant #3 safe sleep plan to CCLD by 8/1/2022, via email to: Martina.Jimenez@dss.ca.gov
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, interview with licensee and record review, revealed infant #3 file not to have document for time of each 15-minute check, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee will submit verification infant #3 document for time of each 15-minute check to CCLD by 8/1/2022, via email to: Martina.Jimenez@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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4