566211061-11-2-2022-17-CC-ARIS-CKSU5P-20221102151706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566211061
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:17:20 PM

Document Has Been Signed on 11/02/2022 03:17 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:	MORA FAMILY CHILD CARE		FACILITY NUMBER:	566211061
ADMINISTRATOR:	DOLORES MORA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 212-6315
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY:	14	CENSUS: 5	DATE:	11/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Dolores Mora		TIME COMPLETED:	03:38 PM

NARRATIVE

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On November 2, 2022 at 1:20 PM Licensing Program Analyst (LPA) Austin Rios conducted an unannounced annual inspection. LPA met with licensee Dolores Mora and discussed the nature and purpose of the inspection. Together both licensee and LPA conducted a tour of the home inside and outside. There was five children in care at the time of the inspection. LPA observed the home to be clean and orderly.

The licensee uses the living room, playroom, kitchen, one restroom, and backyard for the day-care. LPA observed bedroom doors to be closed and locked. There are no bodies of water in the home. Licensee states that there are no firearms and ammunition in the home. LPA did not observe toxins/hazards accessible to children in care. In the family room,. There are age appropriate toys and furniture readily accessible to children. The backyard is fully enclosed with a concrete wall. . Licensee has age appropriate toys and play structures in the backyard in good condition and free of hazards. Licensee has a trampoline with a net in the backyard. LPA reminded licensee to follow manufacture guidelines.

The home has a working smoke and carbon monoxide detector. A 2A10BC fire extinguisher was observed in the kitchen with a service date of 10/25/2022.

A roster of children in care was observed current and complete. A sampling of children's records were reviewed. Licensee is missing signed parent rights (LIC) 995A in the children's files. California Code of Regulation, (Title 22 Division 12 and 102419(d) type B deficiency is being cited on the attached LIC 809 D)

Cont. on 809-C.

SUPERVISOR'S NAME: Ana Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin Rios	TELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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: MORA FAMILY CHILD CARE	FACILITY NUMBER: 566211061
	VISIT DATE: 11/02/2022

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Licensee has a valid Pediatric CPR/First Aid certificate with an expiration date of 9/27/2024. Licensee has AB 1207 Mandated Reporter Training Certificate on file expiring on 10/13/2023. The last fire drill was conducted on 10/1/2022. All required forms are prominently posted for parent's or authorized representatives in the play room. Licensee does not have any infants enrolled.

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.

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.

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

SUPERVISOR'S NAME: Ana Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin Rios	TELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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: MORA FAMILY CHILD CARE	FACILITY NUMBER: 566211061
	VISIT DATE: 11/02/2022

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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.

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

Exit interview conducted and report was reviewed with the licensee Dolores Mora.

SUPERVISOR'S NAME: Ana Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin Rios	TELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/02/2022 03:17 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: MORA FAMILY CHILD CARE	FACILITY NUMBER: 566211061
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)

Admission Procedures and Parental and Authorized Representative's Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as no parent rights forms were signed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2022
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Tolentino	TELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Austin Rios	TELEPHONE: (805) 635-4725
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

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