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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629756
Report Date: 04/28/2025
Date Signed: 04/28/2025 10:47:19 AM

Document Has Been Signed on 04/28/2025 10:47 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CEVEILLARD, MIKA FAMILY CHILD CAREFACILITY NUMBER:
376629756
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 0DATE:
04/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mika CeveillardTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On April 28, 2025, at 9:15 a.m., Licensing Program Analyst (LPA), Angela Nguyen conducted an unannounced Annual/ Random Inspection and met with Licensee, Mika Cevelliard. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. LPA utilized Multilingual interpretation services during the inspection to translate in Haitian Creole, Interpreter # 56222062. There were no day care children present during the inspection. This facility is a single story, three (3) bedroom, two (2) bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care: Living room, bathroom #1, day care room and front yard. Off limits areas: Bedroom #1, #2, #3 with included bathroom, kitchen, backyard and garage. Off limits areas are made inaccessible by the use of door knob covers at the time of inspection and child proof gates. Hours of operation: Monday- Sunday 6:00 a.m. to 11:59 p.m.

The fire extinguisher, smoke detector, and carbon monoxide detector were inspected and met requirements. Hazardous items were made inaccessible to children during the inspection. The licensee has toys, play equipment and materials available. The home has a fenced front yard for outdoor play. The home has a fireplace in the living room with a safety gate covering the opening. Licensee stated there are no bodies of water on the premises and LPA did observe an empty fountain filled with rocks in the middle of the front yard in the day care area during the inspection. Licensee stated there are no firearms or ammunition in the home. Child records were reviewed and determined to be complete.

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
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CEVEILLARD, MIKA FAMILY CHILD CARE
FACILITY NUMBER: 376629756
VISIT DATE: 04/28/2025
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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’s First Aid and CPR certification expires on 04/2027. Licensee has required immunizations on file. Licensee completed Mandated Reporter Training on 4/26/2025 and expires on 04/2027. Facility roster was reviewed. The disaster drill was conducted and documented on 04/03/2025.

LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided information regarding SIDS, Lead exposure and Shaken Baby Syndrome.

Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA advised Licensee if there is an unusual incident to report to call Licensing within 24 hours and to follow up with an LIC624B within 7 days. In addition, for general questions, questions regarding licensing requirements call Child Care Licensing. Duty Line at (619) 767-2248. Access our updated Regulation & Forms by using our WEBSITE: http://ccld.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov.
Incidental Medical Services (IMS) policy was discussed with Licensee, Sahra Abdi. 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/.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CEVEILLARD, MIKA FAMILY CHILD CARE
FACILITY NUMBER: 376629756
VISIT DATE: 04/28/2025
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LPA advised the Licensee that prior to making alterations or additions to the home or grounds, the Licensee shall notify the Department of the proposed change.

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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Southern California Child Care Advocate information was provided, and applicant was encouraged to subscribe through the CCLD website to be placed on an email list for updated regulation information. Advocate information was provided: (714) 703-2800 or childcareadvocatesprogram@dss.ca.gov.

On 02/27/2025, Licensee submitted an application for a large license for up to 14 children. A fire clearance for 14 children was granted on 03/12/2025. During today’s inspection, LPA observed the facility has ample space to care for up to 14 children.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CEVEILLARD, MIKA FAMILY CHILD CARE
FACILITY NUMBER: 376629756
VISIT DATE: 04/28/2025
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Licensee stated she does not have an assistant designated however, she will submit requirements to the Department when she has one.

The maximum capacity for a large family child care home: 12 children (with a qualified assistant) with no more than 4 infants; or (with landlord consent) 14 children (with a qualified assistant) with no more than 3 infants, 1 child enrolled in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. When there are no Qualified Assistants present, the capacity reverts to the requirements for a Small Family Child Care. To access our Regulations and Forms please use our WEBSITE: http://ccld.ca.gov.

One (1) type B California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

A Large Family license may be issued once deficiencies are corrected.

A Notice of Site Visit (LIC 9213) was given to Licensee, Mika Cevelliard and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. LPA observed LIC 9213 was posted. Appeal Rights (LIC 9058) was provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted and the report was reviewed with Licensee, Mika Cevelliard.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2025 10:47 AM - It Cannot Be Edited


Created By: Angela Nguyen On 04/28/2025 at 10:11 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CEVEILLARD, MIKA FAMILY CHILD CARE
FACILITY NUMBER: 376629756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 5 out of 5 childrens files did not have LIC 282 available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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LPA provided copies of the LIC 9150 and LIC 282 to Licensee. Licensee stated that she will have LIC 282 and LIC 9150 filled out the by the parents and updated in the childrens file no later than 5/16/2025.
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.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Angela Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2025


LIC809 (FAS) - (06/04)
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