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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216545
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:43:16 PM

Document Has Been Signed on 09/05/2023 04:43 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:HERNANDEZ LEYVA FCCHFACILITY NUMBER:
426216545
ADMINISTRATOR:EMMA HERNANDEZ LEYVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 332-7563
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Emma Hernandez LeyvaTIME COMPLETED:
04:45 PM
NARRATIVE
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On 09/05/2023, Licensing Program Analyst (LPA) Francisca Velazquez made an unannounced Case Management inspection at the Family Child Care Home (FCCH). LPA met with Emma Hernandez, licensee of the FCCH and explained the nature of the inspection. LPA note nine children are present along with licensee providing care and supervision. LPA notes assistant was out of the FCCH picking up school-age children.

The Case Management inspection follows an unannounced inspection at the FCCH for the purpose of documenting deficiency observed during today's inspection.

At 2:45 PM, LPA observed licensee providing care and supervision to nine children in care without an assistant present in the FCCH. LPA notes out of the nine (9) children present, three (3) children were infant age and six (6) children were between the ages of 2 years through 7 years of age.

At 3:05 PM, assistant/spouse arrived at the FCCH with four (4) additional school-age children.

During today's inspection, deficiency is being cited.

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, Emma Hernandez. Notice of site visit and appeal rights were provided to licensee.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 09/05/2023 04:43 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 09/05/2023 at 03:19 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: HERNANDEZ LEYVA FCCH
FACILITY NUMBER: 426216545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2023
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 was not met as evidenced
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Licensee agrees to submit a written statement detailing how she will ensure ratios and capacity's are always met at the FCCH when one adult is present and when both adults are present in the FCCH. Licensee will submit written plan by 9/6/23 via email to Francisca.Velazquez@dss.ca.gov
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Based on LPA observation, licensee did not met this requirement in that LPA observed licensee providing care for nine (9) children without an assistant. LPA notes three (3) children were infant age which poses an immediate risk to the health, safety and personal rights of children 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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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