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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216142
Report Date: 07/20/2021
Date Signed: 07/20/2021 03:39:39 PM

Document Has Been Signed on 07/20/2021 03:39 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:CALDERON & MACIAS-MEZA FCCFACILITY NUMBER:
426216142
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Maria CalderonTIME COMPLETED:
03:50 PM
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On 7/20/2021 at 12:53 PM, Licensing Program Analyst (LPA) Francisca Velazquez and Licensing Program Manager (LPM) Maria Mueller conducted an announced pre-licensing inspection. Due to COVID - 19 and California Department of Public Health guidelines of social distancing, LPA asked Applicant Pre- Screening questions related to COVID-19. Applicant’s responses to the Pre-screening questions suggest no COVID-19 exposure on site. LPAs met with applicant, Maria Calderon and discussed the purpose of the Inspection.
LPAs conducted the physical plant tour of the home. During this tour the following was noted:

Applicant applied for a Small Family Child Care on 5/17/2021. Family members residing in the home are 2 adults. All adults in the home are fingerprint cleared. Per Applicant, the operating hours will be Monday through Saturday from 8:00 a.m. to 6:00 p.m. Applicant states she wants to care for children from birth to 12 years of age.

All areas identified on the facility sketch were inspected. This is a one story home which consists of two (2) bedrooms, one (1) bathroom, family room, kitchen, dining room garage and backyard. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.
CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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LPA observed the designated day care areas, - family room and dinning area, and bathroom with age appropriate toys, games etc. The back yard is enclosed with wooden fence however, Applicant is currently adding another fence to divide the backyard. One area will be accessible to children in care and the other area of the backyard will not be accessible to the children in care. There are no bodies of water observed.

Off limit areas included: 2 bedrooms, kitchen, garage and part of the back yard. Kitchen is made inaccessible by a child safety gate. Bedroom and garage door knobs have plastic safety cover.

Areas used by children included: living room, dinning area, and the bathroom located in the hallway. Once the fence in the backyard is complete, the backyard will also be accessible to the children in care. There are age appropriate toys and materials for children on the premises. Knives are stored out children’s reach, inaccessible to children in a high locked cabinet in the kitchen.
The required fire extinguisher 2A10BC was purchased on 7/20/21. Smoke detector, carbon monoxide detectors were tested at 1:27 PM and were functioning at the time of the visit. Per Applicant, there are no guns nor ammunition in the home. First Aid and emergency kits are available. The Applicant completed the Orientation on 2/6/20. The Applicant has current Pediatric First Aid and CPR which expires, 3/7/2022. Applicant completed Preventative Health Training 5/22/2020. Applicant completed the Mandated Reporter Training on 6/24/2021. Applicant has proof of immunization per SB 792 against influenza, pertussis, and measles.

CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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The following was discussed with the applicant:
· Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization's, and a valid criminal record clearance associated to the facility license.


· A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.
· The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
· Changes in the home should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if applicant moved to another location/ home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements were reviewed and explained.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a Family Child Care Home, 24/7.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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Incidental Medical Services (IMS) policy was discussed
For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

· All adults living and working in the home shall be made of aware of the Department inspection rights authority.



· Safe Sleep Regulation, (PIN 20-24). Shaken Baby Syndrome, and COVID-19 guidelines. The “Effects of Lead Exposure” brochure is to be distributed to all families at time of enrollment. It is the Applicant's responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.
· Infant up to 12 months of age must be on their backs to sleep, unless there is a medical exemption from a licensed physician that allows for an alternative sleeping position.
· Cribs must be free from all loose articles and objects, including blankets and pillows.
· Mattress must be firm and include a tight-fitted sheet.
· infants must not be forced to sleep, stay awake, or stay in the sleeping area.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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· Infants must not be swaddled while in care.
· An infant's head must not be covered while sleeping.
· If an infant falls asleep before being placed in a crib, for example, in a provider's arms or stroller, the provider must move the infant to a crib (or play yard for FCCHs) as soon as possible.

Car seats will only be used for transportation and must not be used for sleeping within a childcare facility.


· All pacifiers cannot have anything attached, such as a stuffed animal or a clip meant to attach the pacifier to the infant's clothing.
· Providers must check on sleeping infants (0 to 24 months) every 15 minutes and document their condition to check for signs of distress, which includes, but is not limited to labored breathing, flushed skin color, increase in body temperature, and restlessness.
· Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

LPA also advised against sleeping infants in a separate room.

During this visit, the LPA reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the applicant. LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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Forms to be posted
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License

Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse.

Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).



LPA reviewed COVID-19 Self-Assessment Guide with applicant and informed applicant to post COVID-19 documents.

Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights

Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

Exit interview was conducted with, Maria Calderon. 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: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: CALDERON & MACIAS-MEZA FCC
FACILITY NUMBER: 426216142
VISIT DATE: 07/20/2021
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The home meets Title 22 Division 12 California Code of Regulations requirements of a Small Family Child Care Home (FCCH). Effective date of license is 7/20/2021.


Pre Licensing inspection was conducted in Spanish and English and Report was translated by LPA Velazquez in Spanish.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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