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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215742
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:12:01 PM


Document Has Been Signed on 03/30/2023 05:12 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:CABRERA FCC AKA NADIA'S DAYCAREFACILITY NUMBER:
426215742
ADMINISTRATOR:ELIA CABRERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 287-9131
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:14CENSUS: 7DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Elia CabreraTIME COMPLETED:
05:20 PM
NARRATIVE
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On 3/30/2023, Licensing Program Analysts (LPA) Martina Jimenez, conducted an unannounced Case Management inspection to follow up on a Self Reported of an Unusual Incident Report (UIR) received by the Department on 3/29/2023.

LPA met with Elia Cabrera, Licensee, the purpose of the inspection was discussed. LPA with licensee together tour the inside and out side of home. LPA observed 1 infant and 1 child in care at the time of LPAs arrival.. LPA observed at 3:30pm, Nadia Hernandez Cabrera, Assistant, arrived with 5 children. The licensee stated the assistant picked up the 5 children from school.

LPA interviewed Elia Cabrera, in reference to the incident that occurred on 3/29/2023. The licensee stated the last date C1 attended the day-care was 3/24/2023. Licensee stated C1 started attending the day-care full time, but since January 2023, C1 started to attend 2-3 days a week depending on mother's work schedule.

Licensee stated that on 3/24/2023, licensee observed C1 to have had a normal day. Licensee stated C1 was not sick, C1 ate normal, and slept normal (approximately 2 hours). Licensee stated that licensee did not observed any injuries or marks on C1 the last day in care.

The licensee stated that on 3/29/2023, licensee completed a Safe Sleep Plan (LIC9227), for C1, and that is the reason the Safe Sleep Plan does not have mother's signature.

The licensee will continue to monitor and document infant 's Safe Sleep Plan and Infant's Safe Sleep Chart.

This Report continues on LIC 809C & LIC 809D
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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: CABRERA FCC AKA NADIA'S DAYCARE
FACILITY NUMBER: 426215742
VISIT DATE: 03/30/2023
NARRATIVE
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LPA provided licensee with resources on how children understand death and what to say and supporting the family after the death of a child.

Today, deficiency cited under Title 22 Division 12, Spanish, Appeal rights given. THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. 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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/30/2023 05:12 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: CABRERA FCC AKA NADIA'S DAYCARE
FACILITY NUMBER: 426215742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited

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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: interviewed with licensee, the licensee
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licensee will submit a written statement on how licensee will prevent future incidents , via email by 04/06/2023.

Martina.Jimenez@dss.ca.gov
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 stated that on 3/29/2023, licensee completed a Safe Sleep Plan (LIC9227), and that is the reason the Safe Sleep Plan does not have mother's signature, which poses/posed a potential health, safety or personal rights risk to persons 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: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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