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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216582
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:49:16 PM

Document Has Been Signed on 05/26/2023 03:49 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
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GONZALEZ GARCIA FCCFACILITY NUMBER:
426216582
ADMINISTRATOR:ADRIANA GONZALEZ GARCIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 245-9058
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
05/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Adriana Gonzalez GarciaTIME COMPLETED:
04:00 PM
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On May 26th @ 1:30 PM, Licensing Program Analysts (LPAs) Martina Jimenez and Dixie Wright conducted an announced Inspection for the purpose of performing a pre-licensing inspection. LPA asked Applicant Pre- Screening questions related to COVID-19. Applicant's responses to the Pre-screening questions suggest no COVID-19 exposure on site.

LPAs met with Applicant Adriana Gonzalez Garcia,and Carlos Medina Gutierrez, husband. The purpose of the inspection was discussed. Applicant and her husband are the adults living in the home and are fingerprint cleared. Applicant has one minor child living in the home.

Applicant applied for a Large Family Child Care license. Per Applicant, the operating hours will be Monday through Friday from 5:00 a.m. to 5:00 p.m. Applicant states she wants to care for children from 0 months to 12 years of age.

LPAs and Applicant toured the interior and exterior of the home. The home is three bedrooms, two and half bathrooms, attached garage, two story home. All areas identified on the facility sketch were inspected. The Living Room, Dining room, day-care room, kitchen, hallway bathroom and part of the backyard will be accessible to children. LPAs observed a gate at the bottom of the stairs making the three (3) bedrooms and master bathroom inaccessible to children in care. The backyard is completely fenced. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Sharps and cleaning products are all stored inaccessible to children. The garage door and laundry room door had child proof door knobs, making them inaccessible.

Continues on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Dixie Marie Wright
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ GARCIA FCC
FACILITY NUMBER: 426216582
VISIT DATE: 05/26/2023
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The back yard has a locked shed. There is a fenced off area on the left side of the house that is inaccessible to the children. There is age appropriate play structures and a shaded area observed. There was a shaded deck to the right of the backyard. Applicant has one dog with current immunization's that will be in a secure area away from children. There were stepping stones observed in the backyard leaning against the house and stacked on the ground. Applicant stated they are going to be placed down to create a stepping stone path.

The Dining room had age appropriate toys and furniture. Four cots were observed for napping. Applicant has a pack-in-play for infant naps. The applicant states that she will provide food for children in care.

The required fire extinguisher 3A40BC was serviced on 04/24/2023. Smoke detector/carbon monoxide combination alarm was tested at 1:55 PM and was functioning at the time of the visit. Per Applicant, there are no guns and ammunition in the home. First Aid and emergency kits are available.

The Applicant completed the Orientation on 07/20/2022. The Applicant has current Pediatric First Aid and CPR which expires, 04/16/2025. Applicant took the Preventative Health on 04/20/2023. Applicant completed the Mandated Reporter Training on 03/05/2023. Applicant has proof of immunization per SB 792 against pertussis, influenza and measles.

The following was discussed with the applicant:


Individuals who are 18 years of age or older living in the home or working in the home, must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain the Criminal Record Background Check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is
an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization's, and a valid criminal record clearance associated to the facility license.
A current roster of children enrolled must be available for review and maintained for a period of three years, even after children are no longer attending the facility.
The fire extinguisher must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Continues on 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Dixie Marie Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
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
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ GARCIA FCC
FACILITY NUMBER: 426216582
VISIT DATE: 05/26/2023
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Changes in the home should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if applicant moved to another location/ home.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements were reviewed and explained.
Fire and safety drills must be performed every six months and documented for review by the Department.
Smoking is prohibited in a Family Child Care Home, 24/7.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

Incidental Medical Services (IMS) policy was discussed
For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.

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



No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Department inspection rights authority.


During this visit, the LPA reviewed Forms/Records to Keep in Your Family Child Care Home (LIC 311D) with the applicant. LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov


Continues on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Dixie Marie Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ GARCIA FCC
FACILITY NUMBER: 426216582
VISIT DATE: 05/26/2023
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LPA discussed with the applicant Safe Sleep Regulation, (PIN 20-24).
· Infant up to 12 months of age must be on their backs to sleep, unless there is a medical exemption from a licensed physician that allows for an alternative sleeping position.
· Cribs must be free from all loose articles and objects, including blankets and pillows.
· Mattress must be firm and include a tight-fitted sheet.
· Infants must not be forced to sleep, stay awake, or stay in the sleeping area.
· Infants must not be swaddled while in care.
· An infant's head must not be covered while sleeping.
· If an infant falls asleep before being placed in a crib, for example, in a provider's arms or stroller, the provider must move the infant to a crib (or play yard for FCCHs) as soon as possible.
· Car seats will only be used for transportation and must not be used for sleeping within a childcare facility.
· All pacifiers cannot have anything attached, such as a stuffed animal or a clip meant to attach the pacifier to the infant's clothing.
· Providers must check on sleeping infants every 15 minutes and document their condition to check for signs of distress, which includes, but is not limited to labored breathing, flushed skin color, increase in body temperature, and restlessness.
· Each infant, up to 12 months of age, must have an Individual Infant Sleeping Plan (LIC 9227) on file, which will document the infant's sleeping habits, usual sleep environment, and the infant's rolling abilities.

LPA also advised against sleeping infants in a separate room.

Continues on 809-C...
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Dixie Marie Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ GARCIA FCC
FACILITY NUMBER: 426216582
VISIT DATE: 05/26/2023
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Forms to be posted
LIC6101A Emergency Disaster Plan,
PUB394 Notification of Parents Rights Poster,
Facility License

Facility Records: LIC 624B Unusual Incident/Injury Report, LIC 9040 Child Care Facility Roster, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse,
Staff Forms/Records - any assistant present must have the following on file: Proof of TB clearance (within one year).
Children’s records requirements: LIC 700 Identification and Emergency Information, LIC 627 Consent for Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification Additional Children in Care, Immunization record, PUB 72- Family Child Care Consumer Guide, LIC 995A Notification of Parent’s Rights

Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

The home will be Licensed once Applicant submits verification of the following:

1. Secure cabinet where medications are stored.
2. Proof the stepping stones observed leaning against the house in the backyard have been made into a path.

License is pending the above corrections. The applicant will submit verifications of correction, via email by 06/02/2023. dixie.wright@dss.ca.gov
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Dixie Marie Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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