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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216229
Report Date: 06/19/2023
Date Signed: 06/19/2023 02:00:06 PM

Document Has Been Signed on 06/19/2023 02:00 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:PEREZ FCC MAYA'S CAREFACILITY NUMBER:
406216229
ADMINISTRATOR:ANGELICA PEREZ CARDENASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 458-0422
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
06/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Angelica Perez CardenasTIME COMPLETED:
02:15 PM
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Previous Facility Number 406215943

On 6/19/23, at 12:30 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an announced Prelicense/Change of Location Inspection of the abovementioned home and met with Angelica Perez Cardenas, Licensee of the home. LPA informed Licensee of the nature and purpose of the inspection. It should be noted the Licensee's adult child, Natalia Renya Hernandez acted as in interrupter during the inspection and fostered communication between LPA and LIcensee as Licensee is primarily Spanish speaking. Licensee informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from 6:00 AM--6:00 PM, Monday- Friday. Licensee also intends to care for children 0 years of age to 12 years of age. LPA notes, no children are in care at the time of the inspection. As noted above the inspection addresses a change of location to the present residence. The previous facility number is 406215943.

LPA, in the company of Licensee, toured the interior and exterior of the home in its entirety. The home is a three bedroom, two bathroom home. The home's living room, family room, kitchen, hallway bathroom, master bathroom, master room and guest room will be used for child care services, while the backyard and bedroom of the home will be excluded. LPA notes the backyard is under construction and Licensee informed LPA the backyard will be used after construction is completed and authorization is given for use by CCLD.

LPA observed the home to be clean and orderly. The home has spacing and ventilation for children in care. LPA observed vents on the walls of the FCCH. The home has no fireplace and the bathroom to be used for children in care is observed to be clean and free of toxins. Medication in the home is located in the master bedroom's closet on an elevated shelf which is beyond the reach of children and inaccessible. Sharps are located in an elevated cabinet which is beyond the reach of children, while cleaning compounds are located in a secure kitchen cabinet under the sink.
(CONT. 809-C, Page 2)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 3
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: PEREZ FCC MAYA'S CARE
FACILITY NUMBER: 406216229
VISIT DATE: 06/19/2023
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LPA observed a fire extinguisher (2A10BC) in the home which was serviced on 5/18/23. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has numerous combination smoke and carbon monoxide detectors. A detector in the living room was tested at 12:45 PM and found to be operable.

As noted, the backyard is excluded from care at this time. The Licensee will take children in care to neighboring parks until construction is complete in the backyard of the home and the area is approved for use by CCLD. Licensee is reminded to ensure children in care are directly supervised when traveling outside the home and children use age appropriate equipment and structures. LPA observed no bodies of water present.
LPA's record review revealed Licensee's' Mandated Reporter training was completed on 6/5/22 (expiration 6/5/24), and Pediatric CPR/First Aid (EMSA approved) training was completed on 1/29/22 (expiration 1/29/24). Licensee completed Preventative Health Training on 3/7/22. LPA reminded Licensee of obligation to maintain current training and certifications. LPA reviewed Licensee's control of property document (Home Loan Documents). Licensee does have liability insurance for the home. Licensee informed LPA
no ammunition and firearms are 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 Homes and the ADA, available at: http://www.ada.gov/childqanda.htm

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at

(CONT. 809-C, Page 3)

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

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PEREZ FCC MAYA'S CARE
FACILITY NUMBER: 406216229
VISIT DATE: 06/19/2023
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https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

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 platform.

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.

Exit interview conducted and report was reviewed with the Licensee Angelica Perez Cardenas. The home meets Title 22 Division 12 requirements of a Large FCCH and a change of location has been granted, effective 6/19/23.

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

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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