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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210510
Report Date: 05/20/2025
Date Signed: 05/20/2025 01:37:50 PM

Document Has Been Signed on 05/20/2025 01:37 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:PEREZ FCC AKA LITTLE BLESSINGSFACILITY NUMBER:
426210510
ADMINISTRATOR/
DIRECTOR:		ANA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 588-7277
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/20/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Ana PerezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On May 20, 2025, at 12:15 PM Licensing Program Analysts (LPAs) Elizabeth George and Bill Billones conducted an unannounced case management inspection and met with Licensee Ana Perez. The purpose of the inspection was to provide the facility with a copy of the Decision and Order to exclude Individual #1, for a period of two years, and to conduct a Confirmation of Removal (COR) to ensure Individual #1 is not present at the facility. At the time of the inspection, 9 children were present with 3 staff members.

During the inspection, LPAs did not observe Individual #1 at the facility. Per the Licensee, Individual #1 does not reside or work at the facility. The Licensee provided the LPAs with a signed Confirmation of Removal (LIC 300B) for Individual #1.

The Licensee was informed she is required to notify parents of children currently in care Individual #1 has been removed from the facility. The Licensee must have a signed copy of the Addendum to Notification of Parent’s Rights (LIC 995B) for each child in care.

Individual #1 is prohibited from employment in, presence in, and contact with clients of any facility licensed by the Department, certified or approved by a licensed foster family agency, or any resource family home. Individual #1 is also prohibited from holding the position of board member, executive director, or officer of any licensed facility for a period of two years, ending May 29, 2025.

The following documentation was provided and explained during the inspection:
· Decision and Order – CDSS No. 7824080002
· A copy of the Exemption Denial Letter dated March 4, 2024
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Ana Tolentino
NAME OF LICENSING PROGRAM ANALYST: Elizabeth George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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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: PEREZ FCC AKA LITTLE BLESSINGS
FACILITY NUMBER: 426210510
VISIT DATE: 05/20/2025
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An exit interview was conducted with Licensee, Ana Perez. A copy of the Appeal Rights (LIC 9058 FAS 01/16) was provided and explained. The Licensee's signature on the form acknowledges receipt of these rights.

Verification of removal is complete. No deficiencies cited.

The Notice of Site Visit (LIC 9213) has been posted. This notice must remain posted for 30 consecutive days. Failure to maintain this posting as required will result in a $100.00 civil penalty. Copies of this report must also be posted for 30 days in a visible location accessible to the authorized representatives of children in care.
NAME OF LICENSING PROGRAM MANAGER: Ana Tolentino
NAME OF LICENSING PROGRAM ANALYST: Elizabeth George
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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