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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115406189
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:21:53 AM

Document Has Been Signed on 06/14/2022 11:21 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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:ZARAGOSA FAMILY CHILD CARE HOMEFACILITY NUMBER:
115406189
ADMINISTRATOR:ZARAGOSA, NICKY & THEODOREFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 865-3906
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nicky ZaragosaTIME COMPLETED:
11:30 AM
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On 6/14/22 at 10:15am, an annual required inspection was made to the facility by Licensing Program Analyst (LPA), Emilia Grisak. At 10:30am the home was toured inside and outside. The licensees were supervising five children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:30am to 5:15pm, Monday–Friday. Children have access to the entire home except for the master bathroom which has been made inaccessible by door knob covers. The children use the front and back yard and patio area as the outdoor play area and it is not fully fenced and licensee understands that constant visual supervision must be provided while children are outside There were no pools or other bodies of water observed in the yard.
Five children's records were reviewed at 10:46am. Two staff records were reviewed at 11:00am.
There are currently two adults living in the home. The 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. Licensee does not currently have infants enrolled but LPA provided safe sleep information and advised licensee to check United States Consumer
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Emilia Grisak
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ZARAGOSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406189
VISIT DATE: 06/14/2022
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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) 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

he following deficiencies were cited (see LIC 809D): The licensee's First Aid/CPR expired on 1/16/22 and licensee stated she will retake class as soon as possible.



Exit interview conducted and report was reviewed with the licensee Nicky Zaragosa.

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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Emilia Grisak
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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Document Has Been Signed on 06/14/2022 11:21 AM - It Cannot Be Edited


Created By: Emilia Grisak On 06/14/2022 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: ZARAGOSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 2 out of 2 individuals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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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:Erin Virrueta
LICENSING EVALUATOR NAME:Emilia Grisak
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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