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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115406189
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:11:32 AM

Document Has Been Signed on 11/27/2023 11:11 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
CHICO CC RO, 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: 4DATE:
11/27/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Nicky ZaragosaTIME COMPLETED:
11:21 AM
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On 11/27/2023 at 9:46am, an annual inspection was made to the facility by Licensing Program Analyst LPA, S.Sims and T.Dutra. At 10:05am the home was toured inside and outside. The licensees, Nicky Zaragosa and Theodore Zaragosa were supervising 4 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:30am- 5:15pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home is the Master Bedroom, and were made inaccessible by door knob covers. The children use the back yard as the outdoor play area and it is not fully fenced, LPA discussed maintaining constant supervision.

Four children's records were reviewed at 9:50am. Two staff records were reviewed at 9:58am. There are currently 2 adults living in the home.

The following deficiencies were cited: Two counts of LIC 995 missing from Children's files, 1 count of Infant Safe Sleep Log not being documented. (see LIC 809D):


SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ZARAGOSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406189
VISIT DATE: 11/27/2023
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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.
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-andresources/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.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ZARAGOSA FAMILY CHILD CARE HOME
FACILITY NUMBER: 115406189
VISIT DATE: 11/27/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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, Nicky Zaragosa confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the licensee Nicky Zaragosa and Theodore Zaragosa.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2023 11:11 AM - It Cannot Be Edited


Created By: Sydney Sims On 11/27/2023 at 11:05 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: 11/27/2023

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 record review, the licensee did not comply with the section cited above in 1 count of not maintaining safe sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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Licensee will document safe sleep for infant Lane and provide copy of documentation to LPA Sims via text (916) 365 - 5713 by 12/6/23
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

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 count of not maintaining LIC 995 in childrens records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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Licensee will have parents sign LIC 995 and provide copy of documentation to LPA Sims via text (916) 365 - 5713 by 12/6/23
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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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