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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216160
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:33:50 PM

Document Has Been Signed on 10/12/2023 03:33 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
426216160
ADMINISTRATOR:MARYPAZ PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 863-3416
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 17DATE:
10/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marypaz PerezTIME COMPLETED:
03:45 PM
NARRATIVE
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On 10/12/23, Licensing Program Analysts (LPAs) Francisca Velazquez and Martina Jimenez conducted an unannounced Case Management Deficiency inspection at the Family Child Care Home (FCCH) and met with Licensee, Marypaz Perez. The purpose of the inspection was discussed with Licensee.

LPAs arrived to the FCCH at 7:26 AM and observed children getting into a Nissan Pathfinder vehicle that sits up to eight (8) passengers. Per Licensee, all children are being transported to school. LPAs observed eight (8) children sitting in the vehicle and observed four (4) children sitting in the 3rd row of the vehicle, three (3) children sitting in the middle row and one (1) child in the passenger seat. LPAs notified Licensee that the 3rd row of the vehicle only sits three (3) passengers and four (4) children are sitting in the 3rd row. Licensee responded that she will use the larger van Ford F350 that sits up to 12 passengers instead and instructed all children to get out of the Nissan Pathfinder and load into the Ford F350. Licensee proceeded to transport children to school and LPAs entered the FCCH and met with Assistant, Dulce Escobar. Technical violation is being cited due to Licensee almost transporting children in a vehicle that did not have enough seats and seat belts for all passenger in the vehicle.

Inside of the FCCH, LPAs observed five (5) children, of which one (1) was an infant being cared by assistant, Dulce Escobar.

At 7:41 AM, C14 arrived at the FCCH.

At 7:45 AM, C15 arrived at the FCCH.

At 7:56 AM, Assistant Josefina Zamudio de Zavala arrived at the FCCH.

At 8:01 AM C16 arrived at the FCCH. CONT LIC809-C and LIC809-D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 10/12/2023 03:33 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 10/12/2023 at 12:18 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 FAMILY CHILD CARE
FACILITY NUMBER: 426216160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
102416.5(e)

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(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:
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Licensee agrees to submit a written plan detailing how the FCCH will ensure that it is complying with the capacity requirements for the license and will submit the written plan by the end of business day on 10/13/23 via email to Francisca.Velazquez@dss.ca.gov
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Based on LPAs observations and record review it was revealed Licensee was out of ratio from 7:45am until 7:56am. During this time, FCCH had 7 children of which 3 were infant age which is an immediate risk to the health, safety or personal rights risk to persons 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:Maria Mueller
LICENSING EVALUATOR NAME:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2023 03:33 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 10/12/2023 at 01:03 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 FAMILY CHILD CARE
FACILITY NUMBER: 426216160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
102421(a)

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Child's Records - (a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
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Licensee agrees to update all children files and submit proof by the end of business day on 10/19/23 via email to Francisca.Velazquez@dss.ca.gov
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Children record review revealed C1, C2, C3, C7, C8, C9, C11, C13, C14, C15 and C16 had incomplete child records for review in the facility. In addition, C4, C5 and C6 did not have a file for review during inspection which poses/posed an potential health, safety or personal rights risk to persons in care.
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Type B
10/19/2023
Section Cited
CCR102425(c)

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(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. This requirement is not met as evidenced by:
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Licensee agrees to ensure all infant age children have LIC 9227 and submit proof by the end of business day on 10/19/23 via email to Francisca.Velazquez@dss.ca.gov
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Based on record review C9 and C14 did not have LIC 9227 for review which poses/posed an potential health, safety or personal rights risk to persons 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:Maria Mueller
LICENSING EVALUATOR NAME:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


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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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 426216160
VISIT DATE: 10/12/2023
NARRATIVE
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At 8:14 AM, Licensee's daughter, Itzel Vasquez arrived at the FCCH. LPA notes Itzel is also a Licensee, facility number 426215798.Itzel made oatmeal and left the facility at 9:27am.

At 9:18 AM, Licensee, Kiana Nicole Tell arrived at the FCCH. LPA notes Kiana is also a Licensee, facility number 426215738 and left at 9:24am.

At 9:39 AM, C17 arrived at the FCCH.

LPAs initiated a tour of the FCCH with Assistant, Dulce Escobar. LPAs toured the first level of the home that consists of garage, living room, dinning area, daycare room section that consists of two (2) open rooms, bathroom and one (1) bedroom, kitchen, laundry room and bathroom.

At 8:11 AM, LPAs toured the second level of the home which consists of four (4) bedrooms, two (2) bathrooms and outdoor balcony.

At 8:20 AM, Licensee, Marypaz Perez arrived at the FCCH from dropping off children at school. Tour of the FCCH continued with Licensee.

At 8:21 AM, LPAs and Licensee toured the outdoor of the FCCH.

At 8:30 AM, LPAs requested children files for all children present in the FCCH today. Review of children records revealed C1, C2, C3, C4, C5, C6, C7, C8, C9, C11, C13, C14, C15, C16 had incomplete files. See LIC 811 for each child's missing documents.

Review of personnel files and adults present in the home were found to be complete.

After review of children files and date of births, LPAs found FCCH was out of ratio between 7:45AM until 7:56 AM.

During inspection, Licensee used profanity language while referring to her children. LPAs notes this conversation occurred in the dining room of the home while children were in the daycare room areas. Technical violation is being issued. CONT LIC809C and LIC809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 426216160
VISIT DATE: 10/12/2023
NARRATIVE
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Today, deficiency cited under Title 22 Division 12 Appeal rights given. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report.

Exit interview and review of report was conducted in Spanish by LPA Velazquez with licensee, Marypaz Perez. Notice of site visit and appeal rights were provided to licensee.

LPAs left the FCCH to complete the reports at 10:30am and returned to the facility at 2:30pm.

CONT. LIC809D

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

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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