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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215565
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:10:50 AM

Document Has Been Signed on 12/03/2024 11:10 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CHACON FAMILY CHILD CAREFACILITY NUMBER:
426215565
ADMINISTRATOR/
DIRECTOR:		EDIS Y. CHACONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 636-3211
CITY:SANTA BARBARASTATE: CAZIP CODE:
93103
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
12/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Edis Y. ChaconTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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On December 3, 2024 at 9:20 AM, Licensing Program Analyst (LPA) Susana Martinez arrived to the family child care home at to deliver the findings of a complaint. As LPA entered the home, LPA observed Licensee, assistant and an adult (A1) leaving through the back door. LPA conducted a case-management- deficiencies inspection and advised Licensee of the purpose. LPA asked Licensee how many adults were in the home, Licensee hesitated and stated two, LPA asked who had just left through the back Licensee stated it was her child. LPA asked to speak to A1. LPA walked to the front end of the home and caught up to A1 who was driving off.

LPA introduced self to A1 and asked to identify self. LPA asked A1 how she is associated to the facility, A1 stated they live in the home. LPA asked how long they have lived in the home, A1 stated all of their life. LPA asked how old A1 is, A1 stated 20 years of age. LPA asked if she has completed the fingerprint background process, A1 stated no, LPA asked why not, A1 stated they did not know. A1 drove off.

Once inside LPA asked Licensee the reason why A1 was not fingerprint cleared, Licensee stated A1 did not live in the home as they were out of the country. LPA asked where A1 lived, Licensee stated A1 just came back for the Thanksgiving break. LPA asked if she notified the Department, Licensee stated no. LPA asked if A1 would be staying here permanently, Licensee stated yes. LPA advised Licensee that A1 needed to get a criminal record clearance as soon as possible and submit an updated FCCH Application (LIC279) along with A1's TB clearance.

During today's inspection Licensee was issued one Type A deficiency along with a civil penalty. Type A deficiency could be found on the attached 808-D.

LPA S. Martinez informed licensee Edis Y. Chacon that this report dated 12/03/2024 documents one Type A citation which shall be posted for 30 consecutive days as here is/are immediate risk to the health, safety, or personal rights of children in care.

Continued on 809-C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565
VISIT DATE: 12/03/2024
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Also, LPA S. Martinez informed the licensee Edis Y. Chacon to provide a copy of this licensing report dated 12/03/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

LPA provided the following resources:

- Application for FCCH in Spanish (LIC279 SP)

- Request for Live Scan Form (LIC9163)

- Acknowledgment of Receipt of Licensing Reports (LIC9224)

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed in Spanish with Licensee, Edis Y. Chacon.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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Document Has Been Signed on 12/03/2024 11:10 AM - It Cannot Be Edited


Created By: Susana Martinez On 12/03/2024 at 10:17 AM
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: CHACON FAMILY CHILD CARE
FACILITY NUMBER: 426215565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
CCR
102370(d)(1)

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102370(d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility(1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidence by:
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Licensee is to submit proof that A1 conducted a livescan by end of day 12/03/2024. Licensee is to submit an updated application (LIC279). Licensee will be invited into the office for an informal meeting at the Regional Office.
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Based on observation, interviews conducted, and record review, Licensee did not comply with the deficiency cited above as A1 who resides in the home does not have a criminal record clearance which poses an immediate risk to the health, safety and or personal rights of 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:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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