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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210510
Report Date: 10/22/2020
Date Signed: 12/24/2021 10:54:42 AM

Document Has Been Signed on 12/24/2021 10:54 AM - 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 AKA LITTLE BLESSINGSFACILITY NUMBER:
426210510
ADMINISTRATOR:ANA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 588-7277
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/22/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Ana PerezTIME COMPLETED:
04:50 PM
NARRATIVE
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A Case Management Inspection was conducted by Licensing Program Analyst (LPA) S. Mendoza-Ceja who conducted an unannounced tele-inspection due to COVID - 19 State of Emergency. LPA met met with licensee Ana Perez following COVID-19 and Department of Public Health (DPH) guidelines of social distancing.

The purpose of the tele-inspection is to review the incident of July 27, 2020 when child #1 was bouncing aggressively in the My 1st Jump n Slide (bounce house) and jumped from one end of the bounce house to the other causing the bounce house to slide which resulted in child #1 hitting his head on an umbrella pole. Licensee stated she immediately provided first aid to child #1 and notified the parent. Child #1 did not require medical attention. Child #1 is not yet 3 years old and the bounce house was not anchored which poses a potential Health, Safety or Personal Rights risk to children in care.

Based on observation, interview, and record review: the Licensee failed to follow the manufacture directions of the "My 1st Jump n Slide" which indicates children shall be age 3 - 8 years and the product must be used with the anchors provided and installed properly.

The following Type B deficiency is cited according to CCR, Title 22, Division 12 in regards to Operation of a Family Child Care Home. Appeal Rights reviewed.

An exit interview was conducted with Licensee. This report will be sent to the Licensee via email with a read receipt for confirmation of receipt of the email, Licensee shall sign and return via email to LPA S. Mendoza-Ceja. Licensee shall post the "Notice of Site Visit for 30 days".

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2020
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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Document Has Been Signed on 12/24/2021 10:54 AM - It Cannot Be Edited


Created By: Sylvia Mendoza-Ceja On 10/22/2020 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: PEREZ FCC AKA LITTLE BLESSINGS
FACILITY NUMBER: 426210510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2020
Section Cited
CCR
102417(d)

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Operation of a Family Child Care Home. The home shall provide safe toys, play equipment and materials.

This requirement was not met as evidenced by the record review and interview with licensee:
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Please submit a plan of correction to Licensing by 10/26/2020 to ensure this type of violation is repeated.
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Licensee failed to provide safe toys and play equipment when she failed to follow the manufacturer’s directions of the "My 1st Jump n Slide" which revealed 1) the age range 3 years - 8 years and 2) the product must be used with anchors provided and installed properly. Child #1 was not yet 3 years old and the bounce house was not anchored. This poses a potential Health, Safety or Personal Rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Tolentino
LICENSING EVALUATOR NAME:Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2020


LIC809 (FAS) - (06/04)
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