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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215851
Report Date: 05/10/2023
Date Signed: 05/10/2023 06:08:29 PM

Document Has Been Signed on 05/10/2023 06:08 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ALVARADO FAMILY CHILD CAREFACILITY NUMBER:
406215851
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Perla AlvaradoTIME COMPLETED:
06:15 PM
NARRATIVE
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On 5/10/23, at 4:05 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced One Year Required Inspection of the abovementioned Family Child Care Home (FCCH).The inspection was also to address a change of capacity request. LPA met with Perla Alvarado, Licensee of the FCCH and explained the purpose of the inspection. LPA, in the company of the Licensee, toured the interior and exterior of the FCCH. The home’s living room, kitchen, hallway bathroom, bedrooms and side yard are used for child care. At the time of the inspection five children are present.

LPA observed the FCCH to be clean and orderly. The bathroom which is used for care is clean and free of toxins. LPA observed cleaning compounds on the shelf of an elevated cabinet in the laundry room which is inaccessible to children in care. LPA also observed medications in the FCCH stored on elevated cabinet in the laundry room which is also inaccessible to children in care. Toys, furniture and equipment in the FCCH are age appropriate.

LPA observed required licensing forms and documents post on the wall in FCCH's kitchen and outside the door entry. LPA observed a combination smoke and a carbon monoxide detector in the FCCH. The detector was tested 4:20 PM and found to be operable. LPA observed a regulation fire extinguisher in the FCCH's laundry room which was serviced on 3/31/23. LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually.

The FCCH's side yard has cinder block fencing and the footing is cement. The side area is not enclosed. Licensee is reminded to ensure direct supervision is maintained when the area is used for activities. Toys and play equipment observed in side yard are age appropriate. LPA observed no bodies of water on site.

At 4:40 PM, LPA reviewed a sampling of the children's records. The LIcensee had no file for C1, C2 and C3. It should be noted C3 is an infant. As LIcensee had no files for the noted children, immunization records and emergency contact forms were absent among other things. Licensee is reminded the aforementioned should be remained for each children. LPA also reviewed the Licensee's records. The Licensee's records are
(CONT. LIC 809-C)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 05/10/2023 06:08 PM - It Cannot Be Edited


Created By: Elvin Baddley On 05/10/2023 at 05:09 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: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided immunization records for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit Immunization Records for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided immunization records for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit Immunization Recordsfor noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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Page: 2 of 7
Document Has Been Signed on 05/10/2023 06:08 PM - It Cannot Be Edited


Created By: Elvin Baddley On 05/10/2023 at 05:09 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: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided emergecy information cards for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit emergecy information cards for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided contact information for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit contact information for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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Page: 3 of 7
Document Has Been Signed on 05/10/2023 06:08 PM - It Cannot Be Edited


Created By: Elvin Baddley On 05/10/2023 at 05:09 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: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided Notification of Parent's Rights for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit Notification of Parent's Rights for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.

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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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Page: 4 of 7
Document Has Been Signed on 05/10/2023 06:08 PM - It Cannot Be Edited


Created By: Elvin Baddley On 05/10/2023 at 05:09 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: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

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 observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided affidavit for liability insurance for C1, C2 and C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit affidavit for liability insurance for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided Sleep plan for C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submit sleep plan for noted child to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 06:08 PM - It Cannot Be Edited


Created By: Elvin Baddley On 05/10/2023 at 05:09 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: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above as Licensee failed to provided infant file for C3 iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Licensee to submitinfant child for noted children to CCLD (elvin.baddley@dss.ca.gov) by 5/24/23.
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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: ALVARADO FAMILY CHILD CARE
FACILITY NUMBER: 406215851
VISIT DATE: 05/10/2023
NARRATIVE
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current and complete with Pediatric CPR and First Aid certifications expiring in 4/7/25 (EMSA approved) and Mandated Reporter training expiring on 2/5/24. Licensee informed LPA no firearms or ammunition are stored on site.

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

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.

LPAs 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 for additional resource. LPAs 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.

Type B Deficiencies are being cited based on LPAs' observation/interviews/record reviews pursuant to Title 22 of the CA Code of Regulations (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.

A fire clearance was granted for the FCCH for a change of capacity to large (14) on 4/28/23. The change of capacity to a large FCCH is granted today,effective 5/10/23.

Exit interview conducted and report was reviewed with the Licensee Perla Alvarado.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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