<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216212
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:28:02 PM

Document Has Been Signed on 04/01/2022 01:28 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:ORTEGA FAMILY CHILD CAREFACILITY NUMBER:
566216212
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Yanira OrtegaTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 1, 2022 at 11:42AM, Licensing Program Analyst (LPA) Betzayra Cervantes conducted an announced visit for the purpose of performing a pre-licensing inspection. Prior to entering the facility, LPA spoke to applicant Yanira Ortega and conducted a COVID-19 risk assessment. All answers indicated no exposure to COVID-19. LPA discussed the nature and purpose of the inspection. Applicant and LPA toured the facility inside and outside. Applicant and two fingerprint cleared adults were present at the time of the inspection. There were no children present.

The home is a 3 bedroom, 2 bath single story home. The applicant will use the living room, kitchen, front yard and backyard for the day-care. In the living room, LPA observed a converted bedroom which is made off limits by means of a key lock. The 3 bedrooms, 1 bathroom, are off limits and inaccessible to children and locked with a key. LPA observed age appropriate toys and furnishings available for children in care in good condition and free of hazards. In the backyard, the children's play area was observed free of hazards. LPA observed one locked storage shed inaccessible to children. Applicant has a secured fence in the backyard that leads to an off limits fenced off area preventing children from having access. The backyard and front yard to be used are fully enclosed.

LPA did not observe any toxins/hazardous items accessible to children. A regulation 2A10BC fire extinguisher was observed in the kitchen room with a purchase date of 3/28/2022. Applicant is reminded to service or purchase the fire extinguisher yearly. LPA had applicant test smoke and carbon monoxide detectors in the home and were found operational. All adults in the home are fingerprint cleared.

Continued on 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ORTEGA FAMILY CHILD CARE
FACILITY NUMBER: 566216212
VISIT DATE: 04/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed the home to be orderly. No bodies of water were observed on site. Applicant stated that there are no guns or ammunition in the home. Detergents and cleaning compounds are stored out of reach of children. The bathroom to be used for children in care was observed to be clean and sanitary. Applicant states the home does not currently have liability insurance. LPA informed applicant that parents will need to sign a waiver for the liability insurance if insurance is not obtained (applicant was provided form- LIC 282).

Applicant's Pediatric First Aid/CPR certificate is valid until 05/03/2023. AB1207 Mandated Reporter certificate is valid until 02/17/2024. LPA reviewed Mortgage Statement to verify control of property. Preventative Health and Safety and Nutrition Training completed on 05/15/2021.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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.html

LPA issued the applicant updated samples of state required forms to be kept in the children's records. LPA also discussed and provided Guidelines to Safe Sleep and Effects of Lead Exposure leaflets. Applicant was provided information from PIN 20-24-CCP - Recently Approved Safe Sleep Regulations In Effect and LIC 9227 (Infant Sleeping Plan). Applicant was informed that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours. Applicant was made aware of the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.



To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Continued on 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ORTEGA FAMILY CHILD CARE
FACILITY NUMBER: 566216212
VISIT DATE: 04/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Applicant was reminded that all adults 18 and over living or working in the home, 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 licensee 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.

LPA reviewed COVID-19 guidelines/resources with applicant (RAST Technical Assistance Visit completed). LPA also reminded licensee to continue monitoring the CCLD website for COVID-19 updates and guidance. Applicant will implement pre-screening checks, promoting prior hand washing and continuously disinfecting throughout the day.



License to operate a Small Family Child Care facility is effective today, 04/01/2022. Once licensed, the licensee is required to comply with the terms and limitations stated on the license.

Exit interview conducted and report was reviewed in Spanish with applicant, Yanira Ortega.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3