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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426213166
Report Date: 02/18/2022
Date Signed: 02/18/2022 11:00:07 AM

Document Has Been Signed on 02/18/2022 11:00 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:JIMENEZ FCC AKA JIMENEZ CHILDCAREFACILITY NUMBER:
426213166
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
02/18/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Deyanira JimenezTIME COMPLETED:
11:15 AM
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On February 18, 2022 at 9:20 AM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Case Management – COVID-19 inspection and met with, Deyanira Jimenez and Lizzie Mejia-Cueva, Assistant. LPA informed the purpose for the inspection and completed a COVID-19 pre-screening questions prior to the commencement of the inspection. LPA and licensee together toured the inside and outside of the home.

This inspection is a follow-up on COVID-19 outbreaks reported by facility staff to CCL between 12/6/2021 - 12/8/2021. CCL provided a Tele - Rapid Assistance Support Team (RAST) inspection on 7/16/2020, where LPA provided COVID-19 resources, current Childcare Industry Guidance, and a COVID-19 self-assessment guide to the facility.

LPA observed facility staff wearing masks upon arrival to the facility. Children in care also had masks on during this inspection.

LPA discussed facility’s written plan for when a staff member or child tests positive for COVID-19 and developing a written communication plan with parents/guardians to share information and guidelines in their preferred language.

This Report Continues on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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: JIMENEZ FCC AKA JIMENEZ CHILDCARE
FACILITY NUMBER: 426213166
VISIT DATE: 02/18/2022
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LPA discussed COVID-19 Face coverings, Essential Protective Equipment and Supplies, Physical Distancing, Cleaning and Disinfection, Hand-washing, Food Service and Mealtimes, Directed to contact local Public Health for Positive cases and concerns.

LPA reviewed that facility maintains a current Covid-19 Child Care Program Self-Assessment Guide/Mitigation plan. LPA also provided the following resources:

- Official Public Health and Child Care Guidance for COVID-19 – Updated 1/26/2022.
- COVID-19 Child Care Resources:
https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources

Today’s visit was conducted in Spanish by LPA Jimenez. Exit interview conducted and report was reviewed with the licensee, Deyanira Jimenez.

THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS. LPA observed the "Notice of Site Visit" posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
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