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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216199
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:03:46 PM

Document Has Been Signed on 12/15/2021 02:03 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:CHAVEZ FAMILY CHILD CAREFACILITY NUMBER:
426216199
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/15/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ariana ChavezTIME COMPLETED:
02:05 PM
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On 12/15/21, Licensing Program Analyst (LPA) Francisca Velazquez made an announced Prelicensing Inspection of the abovementioned home. LPA met with Ariana Chavez, the Applicant of the home and explained the purpose of the inspection. LPA also met with Applicant's spouse Juan Vidal Hernandez and Applicant's parent Maria Chavez Diaz. Applicant informed LPA of intention to operate the Family Child Care Home, when licensed, from Monday to Sunday, 24/7. LPA observed no children on site during the inspection. Applicant stated that five (5) adults live in the facility, all five (5) adults have been fingerprint cleared.

LPA toured the interior and exterior of the home with the Applicant. The home is a three bedroom, one bath single story dwelling with a detached studio. Applicant stated the home’s family room, dining room, hallway bathroom and backyard will be used for child care, while the bedrooms and detached studio will be excluded from child care services. LPA observed child safety gates at the entrance of the kitchen and in the hallway blocking off one bedroom. Applicant stated that children will go through the kitchen and laundry room to get to the backyard and stated that children will always be supervised while passing the kitchen and laundry room area.

LPA observed the home to be clean, orderly and free of hazards. The bathroom to be used for children care is observed to be clean and free of toxins. Medication in the home is located in the bedrooms of the home which are in an excluded area of care. Detergents and cleaning compounds are stored in the home are secure in a high cabinet by the washing and drying machine. LPA observed a combination carbon monoxide and smoke detector in the home which was found to be operable. Detector was tested at 12:40 PM. The home has appropriate heating and ventilation. LPA observed a regulation fire extinguisher on site which was purchased on 7/21/21. LPA reminded the Applicant to purchase or service a regulation fire extinguish annually. The Applicant informed LPA no firearm or ammunition is on site. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216199
VISIT DATE: 12/15/2021
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The backyard is enclosed by wooden fencing with concrete slab. The area entry/exit gates are secured. The backyard is free of hazards. LPA observed no bodies of water are on site.

LPA toured detached studio in the facility. Tenant stated that she is the only adult living in the studio along with her underage child. Tenant and Applicant both stated that children will not have access to the studio during day care hours.

The Applicant completed Preventative Health training on 5/21/21. Further, the applicant completed Mandated Reporter training on 5/26/21. The Applicant’s Pediatric CPR and First Aid certificate expires on 7/15/23 (EMSA approved). LPA reviewed Applicant's control of property documents. Applicant does not have liability insurance at this time but is planning on getting insurance for her facility. LPA informed applicant to ensure parents sign a waiver for the liability insurance. Applicant was provided LIC 282 form.



LPA observed one dog on site. LPA received vaccinations for the dog which is current. Applicant stated that dog will not be around the children during day care hours.

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


LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Applicant was informed baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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: CHAVEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216199
VISIT DATE: 12/15/2021
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LPA discussed AB 633 and provided Prelicensing packet to Applicant. LPA reviewed and issued the Applicant updated samples of state required forms to be kept in the children's record. LPA also discussed the effects of Lead Exposure leaflets as well as literature related to COVID 19 safeguards and best practices (RAST TA visit completed).

LPA discussed Over night care regulations and left a copy for Applicant to review. LPA assisted Applicant in signing up Applicant's email to receive PIN notification alerts.

Applicant was made aware that it is Applicant's responsibility to know the regulations for Family Child Care Home (FCCH) which can be accessed on-line at www.ccld.ca.gov.

The home meets the requirement for a Small FCCH. License to operate a FCCH is effective today, 12/15/21.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

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

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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