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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566211061
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:56:05 AM


Document Has Been Signed on 01/31/2024 11:56 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:MORA FAMILY CHILD CAREFACILITY NUMBER:
566211061
ADMINISTRATOR:DOLORES MORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 212-6315
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY:14CENSUS: 5DATE:
01/31/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dolores MoraTIME COMPLETED:
11:13 AM
NARRATIVE
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On January 31, 2024 at 9:30 AM, Licensing Program Analyst's (LPA's) Susana Martinez and Aaliyah Zendejas conducted an unannounced Required- 3 Year inspection. LPA's met with licensee Dolores Mora and advised her the purpose of the inspection. Licensee provided LPA's a tour of the home inside and out. At the time of inspection there were 5 children in care and 3 fingerprint cleared adults in the home.

LPA asked Licensee for the required licensing documents that need to be posted in a prominent publicly accessible are, Licensee states she does not have them posted and instead put them in a file. LPA's advised Licensee that the Facility License, Notification of Parent's Rights- PUB394, and Earthquake preparedness- LIC9148, need to be posted for view of parents/authorized representatives. Fire extinguisher 2A10BC mounted on the wall inside the school room was last serviced 10/04/2023. Fire and carbon monoxide detectors were tested at 9:44 AM and found to be working. LPA's asked for documentation of disaster drills being conducted, Licensee admits that she has not kept up up with this requirement. Last drill was observed to be conducted 07/05/2023.

Children in care have access to the main day-care room, one restroom, kitchen, living room, and fenced back yard. Kitchen knives are being kept in a cabinet above counters to keep out of reach from children. Children have access to toys that are age-appropriate inside and outside of the home. Back yard play area is enclosed and has plenty of play structures and activities. No bodies of water were observed at the time of inspection.

LPA reviewed five out of five children files. During record review LPA's observed two children's files to be missing immunization records. At 10:40 AM LPA's asked Licensee for immunization's for the two children, Licensee states she does not have them. Licensee CPR/first aid is valid through 06/23/2025. Licensee was reminded a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter certification AB1207 every two years at www.mandatedreporterca.com. Licensee's mandated reporter certificate was valid through 10/2023.

Continued on 809-C
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MORA FAMILY CHILD CARE
FACILITY NUMBER: 566211061
VISIT DATE: 01/31/2024
NARRATIVE
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LPA's observed two trampolines in the a backyard. LPA's reminded Licensee of the following information.
TRAMPOLINE CONDITIONS:

1. Follow appropriate age limit and warnings designated by manufacture when using the trampoline.
2. There will be one fully qualified adult and/or the licensee directly and in the presence of children playing on the trampoline. The licensee may be one of the adults supervising the children.
3. If children are in care who are not using the trampoline, those children shall be supervised by a qualified adult.
4. The licensee shall inspect the trampoline on a daily basis and immediately before its use to ensure its safety and that it is in good repair and condition.
5. The trampoline shall only be used in a safety cushioned area.
6. If there are any injuries as a result of the use of the trampoline requiring medical attention, the licensee is required to report this incident to the licensing office within 24 hours by telephone followed by a written report (LIC 624 B) within 7 days from the day of the incident.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Dolores Mora, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.


Continued 809-C
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: MORA FAMILY CHILD CARE
FACILITY NUMBER: 566211061
VISIT DATE: 01/31/2024
NARRATIVE
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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 does not have any infants in care at the moment. Per record review, Licensee has one child under 24 months.

Licensee advised there were no children in care that required Incidental Medical Services. 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's provided the following resources to the Licensee:


-LIC311D- Forms/Records to be Kept in your FCCH
- PUB394 Notification of Parent's Rights
- Reminder to conduct fire drills
- LIC627 Consent for Medical Treatment
- Safe Sleep Log
- Safe Sleep FAQ's
- LIC9227- Individual Safe Sleep Plan

During today's inspection 4 Type B citations and 1 Technical Violation were issued. Type B citations can be found on the attached 809-D.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted, appeal rights were given and report was reviewed with the licensee Dolores Mora.

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/31/2024 11:56 AM - 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117


FACILITY NAME: MORA FAMILY CHILD CARE
FACILITY NUMBER: 566211061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of one infant is missing safe sleep documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee agreed to read the Safe Sleep Frequently Asked Questions and submit a statement indicating what she has learned.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as mandated reporter certificate was valid through 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee is to complete the mandated reporter training and provide proof of completion to LPA by 02/14/2024.
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: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 01/31/2024 11:56 AM - 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117


FACILITY NAME: MORA FAMILY CHILD CARE
FACILITY NUMBER: 566211061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as documents were not posted in the home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee is to post required documents and submit proof to LPA by 02/14/2024.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 5 children's records were missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee is to submit proof of children's immunization records to LPA by 02/14/2024.
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: Susana MartinezTELEPHONE: 805-689-4212
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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