566216060-11-23-2020-17-CC-MAVA-BVMUBH-20201123142621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566216060
Report Date: 11/13/2020
Date Signed: 11/23/2020 02:26:30 PM

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:	NUNEZ FAMILY CHILD CARE		FACILITY NUMBER:	566216060
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 1	DATE:	11/13/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Lorena Nunez		TIME COMPLETED:	04:18 PM

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	On 11/13/2020 at 3:00pm, Licensing Program Analyst Michael Avila conducted an announced a change of location from previous facility 566215562. Due to COVID-19 and the Department of Public Health guidelines with regard to social distancing, the inspection was conducted with Licensee Lorena Nunez via Face Time. Prior to the inspection, LPA conducted a tele-inspection pre screening. All responses the Licensee provided to the pre screening questions suggest no COVID exposures on site. The facility is a single story 2 bedroom house with an attached garage. The front and backyard is fully enclosed with a gated fence. No bodies of water were observed on the property. The garage and the master bedroom have been designated as off-limits. Toys and age appropriate furniture were observed in the living room. No toxins nor hazards were observed accessible. A 2A100BC fire extinguisher purchased on 07/12/2020 was mounted on the wall. A smoke and carbon monoxide detector was observed in operable condition. Licensee states there are no weapons, firearms in the facility. Licensee is current in Pediatric First Aid and CPR which expires, 06/26/2022. Licensee took the Preventative Health on 2/24/2018. Licensee provided proof of immunization per SB 792 against influenza, pertussis, and measles. The Mandated Reporter Training AB 1207 was completed on 7/16/2020 . The following was discussed with the applicant: · Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty. *Continued on 809C*

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Michael Avila	TELEPHONE: (805) 722-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

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: NUNEZ FAMILY CHILD CARE	FACILITY NUMBER: 566216060
	VISIT DATE: 11/13/2020

NARRATIVE

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· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization, and a valid criminal record clearance associated to the facility license.
· A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.· The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
· Changes in the home should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if applicant moved to another location/ home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements were reviewed and explained.

· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a Family Child Care Home, 24/7.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

· All adults living and working in the home shall be made of aware of the Department inspection rights authority.

During this visit, the LPA reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the applicants. LPA advised Licensee how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Michael Avila	TELEPHONE: (805) 722-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

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: NUNEZ FAMILY CHILD CARE	FACILITY NUMBER: 566216060
	VISIT DATE: 11/13/2020

NARRATIVE

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Forms to be posted
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License
Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse,
Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).
Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights
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

Control of property was confirmed via review of a rental agreement. LPA Avila discussed and provided COVID19 Self Assessment materials with Licensee. Exit interview was conducted with Licensee Lorena Nunez via tele-inspection, during which appeal rights were explained. This report along with a copy of the appeal rights will be sent to the Licensee via email with a read receipt or confirmation of receipt of email, which will act as the Licensee signature.

License for a small Family Child Care Home is effective 11/13/2020.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Michael Avila	TELEPHONE: (805) 722-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC809 (FAS) - (06/04)

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