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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566209742
Report Date: 09/19/2022
Date Signed: 09/19/2022 03:39:08 PM


Document Has Been Signed on 09/19/2022 03:39 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:ULLOA FAMILY CHILD CAREFACILITY NUMBER:
566209742
ADMINISTRATOR:JUANITA ULLOAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 648-6051
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY:14CENSUS: 3DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Juanita UlloaTIME COMPLETED:
03:58 PM
NARRATIVE
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On September 19, 2022 @ 12:40 PM, Licensing Program Analyst (LPA) Rona Chavez conducted an unannounced annual inspection. LPA met with Juanita Ulloa and was provided a tour of the home inside and out. There were 3 children in care and 1 assistant at the time of the inspection.

The licensee uses the dining room, living room, 1 bathroom, play room and back yard for the day care. LPA observed all required forms are posted on the wall in the playroom. LPA did not observe toxins/hazards accessible to children in care. There are age appropriate toys and furniture readily accessible to children. Licensee states that there are no firearms and ammunition in the home. The home has working smoke and carbon monoxide detectors. A 2A10BC fire extinguisher was observed in the kitchen with a service date of 8/31/2022. The backyard is fully enclosed with a wood fence. Licensee has age appropriate toys and play structures in the backyard in good condition and free of hazards.

Licensee has a valid Pediatric CPR/First Aid certificate with an expiration date of 6/2023. Licensee and assistant have current AB1207 Mandated Reporter Training Certificate on file expiring on 08/04/2023. The last fire drill was conducted on 08/31/2022.

A roster of children in care was observed and was missing information on currently enrolled children. Licensee stated she has the copy but is unable to locate. A sampling of children's records were reviewed and found complete. LPA reviewed staff file and Licensee was missing copy of LIC 9052 Employee Rights. Licensee was provided a copy of the missing form and a list of required forms/records for children and staff. Licensee states she does not currently provide IMS to children in care.

Cont on LIC 809C

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Rona ChavezTELEPHONE: (424) 299-1480
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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Document Has Been Signed on 09/19/2022 03:39 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: ULLOA FAMILY CHILD CARE
FACILITY NUMBER: 566209742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022

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 record review, the licensee did not comply with the section cited above in 1 out of 1 file. Licensee did not have a current Infant Sleeping Plan on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2022
Plan of Correction
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Licensee will provided a copy of LIC 9227 to LPA by above due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Rona ChavezTELEPHONE: (424) 299-1480
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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: ULLOA FAMILY CHILD CARE
FACILITY NUMBER: 566209742
VISIT DATE: 09/19/2022
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Licensee observed current and complete Infant sleep logs of 15 minute checks. File for 1 infant was incomplete and missing LIC 9227. Licensee states she did not know about the document and will have it filled out by parents immediately.

During today's inspection, one (1) Type B deficiency was cited under Title 22 Division 12. Two (2) Technical Violations were issued and resources provided.


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


LPA discussed the safe sleep regulations with licensee 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 licensee 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. Licensee was reminded that all adults 18 and over living or working in the home, 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.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Rona ChavezTELEPHONE: (424) 299-1480
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ULLOA FAMILY CHILD CARE
FACILITY NUMBER: 566209742
VISIT DATE: 09/19/2022
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Incidental Medical Services (IMS) 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 IMA 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

Licensee was reminded that all adults 18 and over living or working in the home, 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.

Report reviewed with licensee. Copies of reports and appeal rights were provided.

An exit interview was conducted with Licensee Juanita Ulloa. .

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Rona ChavezTELEPHONE: (424) 299-1480
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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