406216539-2-23-2023-17-CC-GRES-CPBRM7-20230223120818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406216539
Report Date: 02/23/2023
Date Signed: 02/23/2023 12:08:27 PM

Document Has Been Signed on 02/23/2023 12:08 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:	NUNEZ SHOGREN FCC		FACILITY NUMBER:	406216539
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS:	DATE:	02/23/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Adriana Nunez Shogren		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On February 23, 2023 at 9:15 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an announced pre-licensing inspection and met with Applicant, Adriana Nunez Shogren. LPA asked pre screening questions related to COVID-19, applicant's responses indicate there are no COVID-19 exposure on site. LPA discussed the purpose of the inspection. LPA in the company of the applicant toured the home inside and outside. The home is a four storey situated in a one acre property. It is composed of composed of 5 bedrooms, 3 baths. Areas accessible to children will be the 1st level of the home where most of day care activities will be held. Day care children will be accompanied to bathroom which is located in the 2nd level. 3rd level is the home's living room, kitchen and dining which will also be accessible to children during meal times. 4th level where the bedrooms are will not be accessible children in care. The backyard is fenced up with wire chain link. A small portion of the backyard which is also enclosed will be used as play yard by day care children. Garage is at the back of the home which house the dogs. There are hens, chickens, turkey and goats are enclosed in the backyards. LPA observed age appropriate toys, equipment and cots in the day care area. The 2A10 BC fire extinguisher was serviced on 1/26/2023. There are carbon monoxide and smoke detectors which were tested and found to be functional. Applicant stated there are no guns and ammunition in the home, nobodies of water was observed. Continued on LIC 809 C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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: NUNEZ SHOGREN FCC	FACILITY NUMBER: 406216539
	VISIT DATE: 02/23/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Ms. Nunez Shogren completed the Family Child Care orientation on 3/15/2022. Applicant is enrolled to take Preventative Health and Safety Training on 3/25/2023. Pediatric First Aid/CPR certificate expires on 1/12/2025 . Mandated Reporter Training expires on 5/4/2024. Applicant was reminded that CPR and Mandated Reporter certificate should be renewed every two years. Applicant stated she does not have liability insurance at this time. LPA discussed the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, Measles, including verification of TB. Applicant's verification is on file.
LPA discussed COVID-19 Mitigation Plan/Self Assessment.

During the tour LPA observed a closet with man's clothing, applicant stated that they belong to an adult child who is currently in the military based outside of the state. They currently have no contacts with the adult individual since the latter is in the field military exercise which is expected to return to base in March 2023.

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 applicant, 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 additional resource. LPA also informed applicant 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 LIC 809C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC809 (FAS) - (06/04)

Page: 2 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: NUNEZ SHOGREN FCC	FACILITY NUMBER: 406216539
	VISIT DATE: 02/23/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Children's record keeping requirements were reviewed.

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.

Issuance of License is pending subject for review and submission of proof that the adult individual does not live in the home and submission of the revised facility sketch.

Notice of Site Visit was issued. Appeal Rights were given and explained.

Exit interview conducted and report was reviewed with the applicant, Adriana Nunez Shoren

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3