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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216264
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:01:23 PM

Document Has Been Signed on 12/08/2022 03:01 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:FONSECA FAMILY CHILD CAREFACILITY NUMBER:
426216264
ADMINISTRATOR:YADIRA FONSECAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 757-1067
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Yadira FonsecaTIME COMPLETED:
03:10 PM
NARRATIVE
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On December 8th 2022 at 1:49PM Licensing Program Analyst (LPA) Rosie Breault made an unannounced inspection for the purpose of initiating a complaint that was reported to the Department. During the course of the inspection, LPA observed a deficiency under Title 22.

In the backyard, LPA observed one large trampoline not covered or locked and accessible to children. LPA observed one large rectangular swing in the fashion of a hammock with no safety barrier and roughly two and a half feet off the ground.

This is in violation of Title 22 Division 12 102417 and a Type B citation will be issued. During the inspection, LPA observed licensee tie up rectangular swing on the structure rendering it out reach to children and inaccessible.

An exit interview was conducted with licensee and a copy of report was provided.

Appeal Rights provide to director.

Notice of Site Visit (LIC 9213) posted during LPA inspection, and must remain posted for 30 consecutive days. Failure to maintain posting as required will result in a civil penalty of $100.00.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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Document Has Been Signed on 12/08/2022 03:01 PM - It Cannot Be Edited


Created By: Maryrose Breault On 12/08/2022 at 02:12 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: FONSECA FAMILY CHILD CARE
FACILITY NUMBER: 426216264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2022
Section Cited

102417(d)

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Home shall provide safe toys, play equipment and materials.
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Licensee to remove trampoline completely (not covered or gated) and provide photo of it inaccesible to children to LPA by 12/9/2022 via text or email at: maryrose.breault@dss.ca.gov
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This evidence was met by:
LPA observed one large trampoline in the back yard and one large rectangular swing with no safety barrier.
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CCR

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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:Maryrose Breault
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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