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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010550
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:22:32 PM

Document Has Been Signed on 03/28/2024 03:22 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MORA ARENAS, EVELYN FCCHFACILITY NUMBER:
283010550
ADMINISTRATOR:MORA ARENAS, EVELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 260-4979
CITY:SAINT HELENASTATE: CAZIP CODE:
94574
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
03/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Evelyn Mora ArenasTIME COMPLETED:
03:30 PM
NARRATIVE
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On 03/28/24 unannounced case management deficiencies visit was conducted. Licensing Program Analyst (LPA) Cindy Castro met with licensee, Evelyn Mora (L1). The facility’s operating hours are 7:00AM- 5:00PM, Monday – Friday. Today's census is 15 children.

At 12:20pm while touring the facility and conducting a headcount, LPA observed 15 children being cared and supervised by licensee and one staff(S1). LPA informed licensee of Staffing and Ratio Capacity, Title 22 Regulations, for a large Family Child Care Home (FCCH). Licensee stated that she is familiar with regulations regarding ratio and capacity.

Licensee further explained that a parent who lives down the street had asked her for a favor, as she needed to go to work for a couple of hours today, and L1 agreed that only for today she would care and supervise her child (C1). L1 added that C1 is on a trial basis currently and is not enrolled permanently. LPA witnessed L1 contact the parent of (C1) to be picked up immediately and parent arrived.

LPA informed the licensee to provide a copy of this licensing report dated 03/28/24 that documents any Type. A citation to parents/guardians of all children currently enrolled by the next business day or the next day the
children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Evelyn Mora. Appeal Rights were provided and discussed. A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior.
side of the main door for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Cindy Castro
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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Document Has Been Signed on 03/28/2024 03:22 PM - It Cannot Be Edited


Created By: Cindy Castro On 03/28/2024 at 02:39 PM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MORA ARENAS, EVELYN FCCH
FACILITY NUMBER: 283010550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
102416.5(d)(2)

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For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time ...shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.
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Licensee contacted parent to pick up C1. Licensee will watch videos on ratio and capacity on the following website:
https://ccld.childcarevideos.org/family-child-care-providers/ and submit a Statement of Understanding to the Department by 03/29/24.
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This requirement is not met as evidenced by:
Based on observation and interview the licensee did not met the ratio requirements by caring for C1 which was a total headcount of 15 children, which poses and immediate Health, Safety and Personal Rights risk to children in care.
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Via mail, email, or fax: (707) 588-5099 Email:cindy.castro@dss.ca.gov

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Cindy Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
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