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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426208912
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:36:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/09/2022 01:36 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:PALACIOS FAMILY CHILD CAREFACILITY NUMBER:
426208912
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Jacova PalaciosTIME COMPLETED:
01:44 PM
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On December 9th, 2022 at 12:04PM, Licensing Program Analyst (LPA) Rosie Breault made an unannounced Annual/Random inspection. LPA met with licensee Jacova Palacios and advised of nature and purpose of inspection. Additionally, licensee submitted a request for increase of capacity which will be addressed during the inspection. Prior to entry the facility, a Covid-19 pre-screening was conducted and licensee stating no exposure to Covid-19 is present. At the time of the inspection there were five (5) children present, licensee and assistant (fingerprint cleared). Licensee provided LPA a tour of the facility both inside and out.

This is a one-story home and licensee utilizes the family room which is gated off and inaccessible, one bathroom and back yard for children in care. Licensee has required documents posted in a prominent place. LPA observed the home to be clean, and orderly with heating and ventilation. LPA observed age appropriate toys, and equipment readily accessible to children. Children utilize mats for napping with individual bedding stored separately and mats are disinfected daily. One crib is currently being used for one child. LPA did not observe any hazardous toxins accessible to children. Back yard had ample shade for children and age appropriate toys and play equipment. No bodies of water were present. Smoke / carbon monoxide detector was tested at 12:25PM and was functioning. Hone has current fire extinguisher with purchase date of 4/26/2022. Fireplace is present in the home in an additional living room, and inaccessible to children by a locked gate. Licensee stated no firearms or ammunition are present in the home.

CONTINUED ON LIC809C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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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: PALACIOS FAMILY CHILD CARE
FACILITY NUMBER: 426208912
VISIT DATE: 12/09/2022
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A sampling of children and staff records was conducted. Children’s files were found to be current and complete. LPA reviewed Individual Sleeping Plans and sleeping logs. Licensee states no Incidental Medical Services are being provided at this time. Staff records were found to be in order. Both licensee and assistant have current Pediatric CPR/First Aid that expires on 11/8/2023 and both Mandated Reporter Training will expire on 4/28/2024.

The home was cleared by Lompoc Fire Marshal on 10/6/2022 stating all safety precautions have been put into place. Areas of use per marshal are as follows: living room, family room, and outside backyard.

Family Child Care Home (FCCH) meets the requirements for a Large FCCH with capacity of 14 effective today December 9th 2022.

No deficiencies were cited during today's inspection.

Notice of Site Visit was provided and to remain posted for 30 days.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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