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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216223
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:11:51 PM


Document Has Been Signed on 03/08/2022 03:11 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:RIVERA FAMILY CHILD CARE HOMEFACILITY NUMBER:
426216223
ADMINISTRATOR:MARIALISA RIVERAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 714-9787
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:14CENSUS: 2DATE:
03/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Marialisa RiveraTIME COMPLETED:
03:20 PM
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On 03/08/2022 at 1:35 PM, Licensing Program Analyst (LPA) S. Mendoza-Ceja met with Marialisa Rivera for the purpose of conducting a pre-licensing inspection. Ms. Rivera was formerly licensed at another location, license #426215938. Entrance Checklist was provided to the applicant. The entire home was toured inside and outside. This a two story home with 5 bedrooms, living room, kitchen, 3 bathrooms, and backyard. Ms. Rivera stated the designated child care areas are the kitchen, dinning area, hallway restroom, and primary day care room, including the backyard. LPA observed the backyard side fences to be approximately 5- 6 feet high and the backside to be approximately 3 feet high. LPA discussed the fencing with applicant. Ms. Marialisa Rivera stated she will be supervising the children in the backyard. LPA observed a gate making the second floor off limits to day care children. Ms. Rivera 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 upstairs bedrooms and two restrooms which were made inaccessible with a gate.

There is a 2 A10 BC Fire Extinguisher (receipt dated 07/21/2021) 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. Ms. Rivera completed Preventative Health and Safety, including Pediatric 1st Aid/CPR certificate expires on 01/24/2023. 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. Rivera completed the Child Abuse Mandated Reporter Training on 09/18/2020 (expires 09/18/2022) and is required to be completed every two years. LPA discussed COVID-19 and obtained the Mitigation Plan. 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. LPA provided the sample forms for applicant.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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: RIVERA FAMILY CHILD CARE HOME
FACILITY NUMBER: 426216223
VISIT DATE: 03/08/2022
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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.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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: RIVERA FAMILY CHILD CARE HOME
FACILITY NUMBER: 426216223
VISIT DATE: 03/08/2022
NARRATIVE
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Prior to licensure the following items shall be corrected:

1. In the backyard, remove or make inaccessible ladders stored on the side of the the home, including other items which pose a hazard.

2. Electrical face plates for outlets and light switches.

3. Control of Property for review.

Exit interview conducted and report was reviewed with the applicant Marialisa Rivera.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Sylvia Mendoza-CejaTELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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