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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406217410
Report Date: 04/04/2025
Date Signed: 04/04/2025 04:33:55 PM

Document Has Been Signed on 04/04/2025 04:33 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:HERNANDEZ-MEDINA FCC AKA LITTLE BLESSINGS DAYCAREFACILITY NUMBER:
406217410
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ-MEDINA, MAYRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 710-7489
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
04/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Mayra Hernandez-MedinaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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This is a change of location, previous facility number is 406216951.

On 4/4/25 at 2:30 PM, Licensing Program Analysts (LPAs) Matthew Sapien and Gigi Reyes conducted an unannounced Prelicensing Inspection for a change of location to the abovementioned residence. LPAs met with Applicant, Mayra Hernandez-Medina. LPAs informed Applicant of the nature and purpose of the inspection. LPA notes 1 child present at the time of the inspection (Applicant's grandson) in addition to the Applicant's husband. Applicant informed LPA the intention to operate their Family Child Care Home (FCCH) Monday through Friday from 6:00 AM until 6:00 PM. The Applicant also informed LPA of the intention to provide care for children 0 years to 12 years of age.

LPAs toured the interior and exterior of the residence with the Applicant. The residence is a one story house consisting of 4 bedrooms and 2 bathrooms. The home's living room (converted day care area), dining room (converted day care area), 1 hallway bathroom, and a portion of the backyard will be utilized for child care. The remainder of the home is excluded from childcare services: all bedrooms, master bathroom, front yard, kitchen, pantry, laundry room, and garage. Importantly to note, all areas that are inaccessible are made secure by child safety gates and locks. All accessible and inaccessible areas were toured thoroughly.

LPAs observed the converted day care areas to have proper spacing and ventilation for children in care. LPAs observed a glass enclosed fireplace near the kitchen in the home. The fireplace is also barricaded by pet cages. Various pet cages were observed in the FCCH containing pets like turtles, birds, and chameleons.

(CONT. LIC 809-C, Page 2)
NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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 5
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSINGS DAYCARE
FACILITY NUMBER: 406217410
VISIT DATE: 04/04/2025
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The hallway bathroom of the residence was observed to be clean and free of toxins. The bathroom has
cabinets that contain common and non-hazardous bathroom items. As an additional precaution, Applicant informed LPAs that child safety latches will be added to the bathroom cabinets. Importantly to note, the hallway area is made inaccessible via a child safety gate. This child safety gate will be opened for children to allow access to the bathroom.

Sharps, medication, and some cleaning supplies are stored in elevated kitchen cabinets. Additional cleaning supplies are stored in the laundry room.

LPAs observed a required fire extinguisher (2A10BC) in the home which was last serviced on 4/11/24. LPAs reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has a number of smoke detectors and carbon monoxide detectors throughout. In the hallway, a smoke detector was tested at 2:45 PM, while a carbon monoxide detector was tested at 3:50 PM. Both detectors were found to be operational.

As mentioned prior, there will be outdoor access for children in care. A portion of the backyard area will be accessible for children in care. This area consists of sizable ceramic flooring and is afforded shade by a wooden pergola, neighboring trees, and by house overhangs. The backyard is fully enclosed by wood fencing throughout. One body of water (a jacuzzi) was observed in the backyard of the house. The jacuzzi was fully covered, however, a lock was not present on the jacuzzi.

LPAs record review revealed Applicant completed Preventative Health training. Further, Applicant completed Mandated Reporter training on 8/29/23, and Pediatric CPR/First Aid training (EMSA approved) on 2/26/24. LPAs reminded Applicant of the obligation to maintain current training and certifications. Because the Applicant rents the residence, Applicant provided the Property Owner/Landlord Notification form (LIC9151) and confirmed it was provided to the property owner/landlord. The Applicant also obtained a signed Property Owner/Landlord Consent form (LIC 9149). The Licensee does currently have renter's insurance for the home. LPA notes no firearms or ammunition are stored on site.

LPAs 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. (CONT. LIC 809-C, Page 3)
NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSINGS DAYCARE
FACILITY NUMBER: 406217410
VISIT DATE: 04/04/2025
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LPAs 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.

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) or (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. Applicant is willing to provide IMS Services depending on the need.

Applicant was informed of the MyChildCarePlan.org site, 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 athttps://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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. (CONT. LIC 809-C, Page 4)
NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSINGS DAYCARE
FACILITY NUMBER: 406217410
VISIT DATE: 04/04/2025
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On this date, 4/4/25, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

A notice of site visit was given to the Applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

The application for a Change of Location is pending for further review and upon completion of the below mentioned:

1. A screen or gate needs to be added to a portion of the backyard separating the accessible area from the non-accessible area of the backyard. Applicant will send over a picture of this through text message or email to LPAs Matthew Sapien and Gigi Reyes.

2. The jacuzzi needs a secure lock added to it making it inaccessible. Applicant will send over a picture of this through text message or email to LPAs Matthew Sapien and Gigi Reyes.

3. An adult in the household, Angel Victoria Pallares Hernandez, has applied for criminal record clearance, however, the request hasn't been fully processed due to the agency/facility number not being listed in the Live Scan Form. Applicant will send over a picture of this through text message or email to LPAs Matthew Sapien and Gigi Reyes.

4. There is a parked RV the driveway of the residence. This belongs to the property owner/landlord. This RV needs to be inspected by the Department or removed entirely.
NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

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

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