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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216477
Report Date: 08/20/2024
Date Signed: 08/20/2024 11:34:05 AM

Document Has Been Signed on 08/20/2024 11:34 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ASUAJE FAMILY CHILD CAREFACILITY NUMBER:
426216477
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Veronica AsuajeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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A follow up inspection was conducted by Licensing Program Analysts (LPAs) S. Mendoza-Ceja and G. Negrete who met with Licensee Veronica Asuaje and informed her of the purpose of the inspection which is to follow up and clear the deficiencies cited on 06/06/2024. During the visit another child arrived during the visit bringing the census to 6.

The following deficiencies are now cleared:

1) 102370(d)(1)&(e) Criminal Record Clearance: 06/12/2024, Licensee submitted verification of live scan of Alba Naicari Asuaje. 06/27/2024, Licensee submitted a plan that will be carried out before anyone begins working as an assistant at Asuaje FCCH will be a scheduled interview and requirements; vaccinations, TB test, first aid course, fingerprints and child abuse course will all be required before you start working at Asuaje FCC. 8/20/2024, Licensee submitted additional written plan every adult will need a fingerprint clearance by the Department before moving in the home.

2) 102416.5(a)(b)12 Staffing Ratio and Capacity: 06/12/2024, Licensee submitted a written plan for review. 06/13/2024, Licensee submitted documentation clarifying which children/ages would be in in care.
06/15/2024, Licensee submitted additional clarification indicating days of when children in care.
06/27/2024, Licensee submitted plan schedule to not exceed not exceed 3 infants (under age 2) and 3 children (over age 2 years).

3) 102417(g)(1)&(4) Operation of a FCCH: 06/09/2024, Licensee submitted pictures of the bedroom doors secured and off limits to day care children. 06/10/204, Licensee submitted receipt dated 06/10/2024 for 2 A10BC Fire Extingusher. 06/27/2024, Plan received to ensure doors are securing during hours operation. Strategy or plan used to ensure the door closes during operating hours. Front door has a child plastic door cover and the gate was secured with safety device and fence photo taken.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Sylvia Ceja
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: ASUAJE FAMILY CHILD CARE
FACILITY NUMBER: 426216477
VISIT DATE: 08/20/2024
NARRATIVE
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 4) 1597.622 (a) (1) Employees or volunteers at family day care home: 06/08/2024, Licensee submitted verification of Alba Naicari Asuaje MMR, Petussis. 06/15/2024, statement declining Flu vaccine received.. 06/27/2024, Licensee stated plan that will be carried out before anyone begins working as an assistant at Asuaje FCCH refer to #1 above.

5) 102369(b)(9) Application for Initial License: 06/08/2024, Licensee submitted verification of Alba Naicari Asuaje TB Test for review. 06/27/2024, Licensee stated plan that will be carried out before anyone begins working as an assistant at Asuaje FCCH refer to #1 above. 08/20/2024, Licensee also submitted a written plan that adults will obtain a TB clearance prior to moving into the home.

6) 1596.8662(b)(1) Child Abuse Mandated Reporter Training: 06/09/2024, Licensee submitted verification of her own completed training AB1207 dated 06/09/2024. Licensee submitted verification of Alba Naicari Asuaje completed AB1207 dated 06/29/2024. 06/27/2024, Licensee stated plan that will be carried out before anyone begins working as an assistant at Asuaje FCCH refer to #1 above.

7) 102417(g)9(A)1 Operation of a Child FCCH: 06/15/2024 Licensee submitted statement to conduct fire drill on 06/18/2024. verification of Fire Drill conducted 06/18/2024.

Further review of children's records revealed licensee accepted an infant without obtaining the records for the child. In addition failed to obtain documentation in regards to infant safe sleep.

The following Type A deficiencies are cited on page #3 and #4 according to CCR, Title 22 Division 12 Regulations in regards to Infant Safe Sleep and Children's Records. Upon receipt, Licensee shall post and provide copies of this licensing report: to parents/guardians of children in care at the facility and to parents/guardian of children newly enrolled at the facility during the next 12 months. Licensee shall obtain signatures of parents/guardian on the Acknowledgement of Receipt of Licensing Reports LIC 9224.

Licensee Veronica Asuaje was advised a Informal Conference will be held at the Santa Barbara Regional office. Licensee was provided a copy of their Appeal Rights (LIC 9058) and Notice of Site Visit form (LIC 9213). Notice of Site visit must remain posted for 30 days.
Exit interview conducted and report was reviewed with the Licensee Veronica Asuaje.

Note: LPA G. Negrete translated the report in Spanish to Licensee Veronica Asuaje.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Sylvia Ceja
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 11:34 AM - It Cannot Be Edited


Created By: Sylvia Ceja On 08/20/2024 at 10:25 AM
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: ASUAJE FAMILY CHILD CARE
FACILITY NUMBER: 426216477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
102425(j)(2)(D)

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Infant Safe Sleep:The provider shall supervise infants while they are sleeping and adhere to the following requirements: (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date. b. Infant’s name. c. Time of each 15-minute check.
This requirement is not met as evidenced by:
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Correct Immediately. Submit a written plan of correction to Licensing for review by 08/21/2024.
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Based on observation, interview with Licensee and record review, the licensee did not comply with the section cited above. Licensee failed obtain document and maintain records of the 15 Iminute infant sleep chart of the five (1) infant infants in care which poses/posed a potential health, safety or peonal rights risk to persons in care.
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Type A
08/21/2024
Section Cited
CCR10425(c)

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Infant Safe Sleep Plan: 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. (1) This plan shall be signed and dated by the infant’s authorized representative. (2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.
This requirement is not met as evidenced by:
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Correct Immediately. Submit a written plan of correction to Licensing for review by 08/21/2024.
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 Licensee failed obtain document and maintain records of the 15 Iminute infant sleep chart of the five (1) infant infant in care which poses/posed a potential health, safety or peraonal 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:Sylvia Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 11:34 AM - It Cannot Be Edited


Created By: Sylvia Ceja On 08/20/2024 at 10:42 AM
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: ASUAJE FAMILY CHILD CARE
FACILITY NUMBER: 426216477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
102421(a)

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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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Correct Immediately. Submit a written plan of correction to Licensing for review by 08/21/2024.
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Based on observation, interview with Licensee, and record review the licensee did not comply with the section cited above. Review of children's files revealed the licensee accepted a child without obtaining child' records which poses a 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:Sylvia Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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