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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216475
Report Date: 12/29/2022
Date Signed: 12/30/2022 08:22:25 AM

Document Has Been Signed on 12/30/2022 08:22 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SIORDIA-DE GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
426216475
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Siordia de GonzalezTIME COMPLETED:
12:23 PM
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On 12/29/2022 at 10:00 AM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an announced Pre-licensing Inspection of the abovementioned residence and met with Applicant, Maria Siordia-De Gonzalez. LPA informed Applicant of the nature and purpose of the inspection. LPA notes there are no children present during this inspection. Applicant informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from 6AM to 4PM, Monday- Friday. The Applicant also Informed LPA of the intention to provide care for children 0 months to 12 years of age.

LPA toured the interior and exterior of the residence with the Applicant. The residence consists of three (3) bedrooms, two (2) bathroom and one (1) studio that is fully equipped with kitchen, bathroom, and bedroom. The home's living room, dining area, kitchen, one (1) bathroom and outdoor yard will be used for childcare services, while three (3) bedrooms, one (1) bathroom and one (1) studio will be excluded from childcare. LPA observed the living room to have spacing and ventilation for children in care. LPA observed a fireplace that is locked and inaccessible to children in care. The bathroom of the residence is observed to be clean and free of toxins. LPA observed sharps in the a drawer of the kitchen that is locked. LPA observed medication in the home is stored in an elevated cabinet in the hallway that is also locked and inaccessible to children in care. LPA observed cleaning compounds are stored in the laundry closet that is locked and inaccessible to children in care.

LPA observed a required fire extinguisher (2A10BC) in the home which was purchased on 12/22/22. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has a smoke and carbon monoxide detector which were tested at 11:57 AM and found to be operable.

LPA observed the outdoor yard to be completely fenced and secured. There is one (1) shed that is locked and inaccessible to children. There is plenty of shade to afford the children in care. Filtered water will be accessible to children by means of individual water bottles. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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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: SIORDIA-DE GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 426216475
VISIT DATE: 12/29/2022
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LPA observed all toys, equipment and supplies used for children are age appropriate.

LPA record review revealed Applicant completed Preventative Health training on 1/21/21. Further, Applicant completed Mandated Reporter training on 10/23/22 and Pediatric CPR/First Aid (EMSA approved) on 2/10/21. LPA reminded Applicant of obligation to maintain current training and certifications. LPA reviewed Applicant's control of property document (mortgage deed). Applicant does not have liability insurance for the home as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282).



LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Maria Siordia-De Gonzalez. The home meets Title 22 Division 12 requirements of a small FCCH license. Effective date of license will be noted as the present, 12/29/22. This inspection and review of report was conducted in Spanish.

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

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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