426216175-3-3-2022-17-CC-SMCA-CC6QQA-20220303112201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426216175
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:22:14 AM

Document Has Been Signed on 03/03/2022 11:22 AM - 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:	PENA FAMILY CHILD CARE		FACILITY NUMBER:	426216175
ADMINISTRATOR:	ANN M PENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 284-3213
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	14	CENSUS: 0	DATE:	03/03/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Ann Pena		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) S. Mendoza-Ceja met with Ann Pena for the purpose of conducting a pre-licensing inspection. Entrance Checklist was provided to the applicant. The entire home was toured inside and outside. This is a single home which has two bedrooms, living room, kitchen, one bathroom, and backyard. Ms. Pena stated the living room, kitchen, restroom, and enclosed patio will be used for day care children. The backyard area beyond the enclosed patio is off limits and was also inspected which includes a storage container and small locked shed which are both inaccessible to day care children. Ms. Pena stated there are no bodies of water, no firearms, nor ammunition in the home. LPA did not observe any bodies of water on the premises. The off limit areas of the home are the two bedrooms which were are key locked and inaccessible to children and backyard which is made inaccessible by a fence. There is a 2 A10 BC Fire Extinguisher in the home. Applicant is reminded to service or purchase the fire extinguisher yearly. There is a carbon monoxide and smoke detector which were tested and found to be functional. Also observed was the mounted Fire Alarm. Ms. Pena completed Preventative Health and Safety, including Pediatric 1st Aid/CPR certificates (expire 07/10/2023). The rental agreement was reviewed and in file. Children's record keeping requirements were reviewed. Ms. Pena stated, she does not have liability insurance at this time. LPA discussed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, Measles, including verification of TB. Verification is on file for applicant. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year or sign a statement declining the influenza vaccine. Ms. Pena completed the Child Abuse Mandated Reporter Training on 08/20/2021 (expires 08/20/2023 and is required to be completed every two years. LPA discussed COVID-19. Applicant provided a Mitigation Plan to the Department, LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

SUPERVISOR'S NAME: Ana Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja	TELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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: PENA FAMILY CHILD CARE	FACILITY NUMBER: 426216175
	VISIT DATE: 03/03/2022

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LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The Fire Clearance was granted on 12/16/2021. Licensure effective 03/03/2022.

Exit interview conducted and report was reviewed with the applicant Ann Pena.

SUPERVISOR'S NAME: Ana Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja	TELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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