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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215128
Report Date: 05/13/2025
Date Signed: 05/13/2025 01:21:55 PM

Document Has Been Signed on 05/13/2025 01:21 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 BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:HOLLOWAY FAMILY CHILD CAREFACILITY NUMBER:
406215128
ADMINISTRATOR/
DIRECTOR:		KIM DENISE HOLLOWAYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 478-2515
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/13/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Kim HollowayTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 5/13/2025, at 11:45 AM, Licensing Program Analyst (LPA) Shane Loftus conducted an unannounced Random/Annual Inspection of the above-mentioned Family Child Care Home (FCCH). LPA met with Kim Holloway, Licensee of the FCCH, and explained the purpose of the inspection. LPA, in the company of Licensee toured the interior and exterior of the FCCH. The FCCH’s living room, dining room, backyard, converted garage and upstairs restroom are used for childcare services, while the home’s bedrooms are excluded from child care. At the time of the inspection, 8 children are present.

The home is orderly. The home does not have a fireplace. The home has ventilation to afford for the children’s comfort and safety. Medication is stored in a medicate cabinet in master bedroom which is excluded from care and inaccessible to children. LPA observed cleaning compounds stored on elevated shelves in the converted garage and kitchen, which is outside the reach of children in care. Sharps are stored in an elevated kitchen cabinet, inaccessible to children in care. LPA observed child safety gates at the base of the stairs. A barricade fence is also in the entry to the kitchen and near the washer in the garage. There is also a child safety gate around the hot water heater in the garage. Toys, furniture and equipment observed in the FCCH are age appropriate.

Required forms are predominantly posted on the wall in the converted garage. The FCCH has smoke and carbon monoxide detectors which were tested (12:09 PM and 12:10 PM) and found to be operable.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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Document Has Been Signed on 05/13/2025 01:21 PM - It Cannot Be Edited


Created By: Shane Loftus On 05/13/2025 at 12:57 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HOLLOWAY FAMILY CHILD CARE
FACILITY NUMBER: 406215128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in that the licenee's Mandated Reporter training expired 4/12/2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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Licensee will submit proof to CCLD (shane.loftus@dss.ca.gov) of current Mandated Reporter training (AB1207) by 5/27/2025.
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.
Maria Mueller
NAME OF LICENSING PROGRAM MANAGER:
Shane Loftus
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HOLLOWAY FAMILY CHILD CARE
FACILITY NUMBER: 406215128
VISIT DATE: 05/13/2025
NARRATIVE
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 LPA observed a regulation fire extinguisher in the FCCH which was service on 5/4/2025. LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually. LPA reviewed the home’s fire/disaster drill log which notes the last drill occurred on 4/18/25.

The backyard is enclosed by a wooden fence. The fence’s entry/exit gates are secure. Toys and play equipment observed in backyard are age appropriate and in satisfactory condition. LPA reminded Licensee to replace outdoor play equipment which begins to degrade or is not in good repair. No bodies of water are observed on site.

LPA reviewed the records of children on site. The records were current, complete and possessed emergency contact information and immunization records. Records also contained Sleep Plans for children and logs documenting the sleep (0-24 months) in 15 minute intervals. The Licensee's records were reviewed. At 12:30 PM, LPA notes the licensee’s Mandated Reporter training expired on 4/12/2025 and CPR/First Aid training expired on 5/2/2025. The Licensee informed LPA no firearm or ammunition are stored on site.

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/.

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. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HOLLOWAY FAMILY CHILD CARE
FACILITY NUMBER: 406215128
VISIT DATE: 05/13/2025
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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.

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

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.

Today, a Type B deficiency is being cited based on LPA’s records review pursuant Title 22 of the Health and Safety Code (refer to LIC 809-D). Licensee was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Kim Holloway.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Shane Loftus
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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