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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215865
Report Date: 03/20/2020
Date Signed: 03/20/2020 01:50:10 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:FLORES FAMILY CHILD CAREFACILITY NUMBER:
426215865
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/20/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Blanca and Rafael FloresTIME COMPLETED:
01:55 PM
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On 3/20/20 at 12:35pm, Licensing Program Analyst (LPA) Melissa Stewart conducted an announced Pre-Licensing Inspection and met with Applicants, Blanca and Rafael Flores. The home was toured inside and out. This is a three (3) bedroom and two (2) bath home. The indoor activity area is located in the front room which has child safety gates at both entry points making the rest of the home inaccessible to children in care. LPA observed pack n play crib, age appropriate toys and furnishings. Three (3) bedrooms, one (1) bathroom, and garage are off limits. The bathroom used by children was observed to be clean and free of toxins. The outdoor activity area is completely fenced; no bodies of water observed. All hazardous items are stored inaccessible to children in care. Applicant stated there are no guns or ammunition in the home.

LPA observed the 10 BC 2.5D Fire Extinguisher with tag dated 2019. Applicant does not have a record of purchase date. Applicant stated that they will purchase a 2A 10 BC fire extinguisher and provide a photo of the receipt showing purchase date. Applicant was reminded to service or replace the fire extinguisher yearly. The home is equipped with working carbon monoxide detector and smoke detector. Applicants have met immunization requirement per SB 792, Preventative Health and Safety course completed on 11/8/19, Pediatric CPR/first aid is current; Blanca's expires on 3/2022 and Rafael's expires on 8/2021. Applicant's have not completed AB 1207 Mandated Reporter Training. Mortgage statement was reviewed. Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2020
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: FLORES FAMILY CHILD CARE
FACILITY NUMBER: 426215865
VISIT DATE: 03/20/2020
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Applicant states that they do not have liability insurance and were reminded to have parents sign a waiver for the liability insurance (LIC 282 provided).

Incidental Medical Services (IMS) policy 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 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: http://www.ada.gov/childqanda.htm

LPA provided Pre-licensing packet to applicant, reviewed and issued updated samples of state required forms to be posted or retained in each child’s file. LPA reviewed and provided applicant with a copy of “Safe to Sleep” brochures in English and Spanish. LPA provided “Effects of Lead Exposure” brochure to be distributed to all families. LPA provided Licensee with California Department of Public Health 2019 Novel Coronavirus Guidance for Child Care and Preschool Settings dated 2/11/20. Applicants were reminded that it is their responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov. LPA guided Applicants through the process of signing up to receive important updates from Community Care Licensing Division via email.

License is pending verification of the following:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2020
LIC809 (FAS) - (06/04)
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