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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216213
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:09:21 PM

Document Has Been Signed on 09/23/2024 12:09 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:FLORES FCC AKA KOODAKAN DAYCAREFACILITY NUMBER:
566216213
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
09/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Erika Flores TIME VISIT/
INSPECTION COMPLETED:
12:24 PM
NARRATIVE
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On September 23, 2024, at 10:31 AM, Licensing Program Analysts (LPAs) Aaliyah Zendejas and Susana Martinez made a unannounced case management- deficiencies inspection at the above mentioned Family Child Care Home (FCCH). LPAs met with Licensee, Erika Flores and explained the nature and purpose of the inspection. LPAs in the company of licensee, toured the FCCH interior and exterior in its entirety. At the time of the visit, there were 2 children under the care and supervision of the licensee and their assistant.

During the tour licensee stated that she was currently doing construction in her backyard. LPAs observed two men in the backyard currently doing work. The men stated that they had begun during the weekend and that it would continue on for another two days. The men stated that the hours were from 8:00 AM - 5:00 PM that they were doing construction work. LPAs asked Licensee if she had called the department regarding their plan to start construction and licensee stated that their attorney was either going to call or had called already. LPA told licensee that it is her responsibility as a licensed child care provider to call and report construction to the department. LPAs provided licensee with a copy of PIN 23-20-CCP

LPAs reviewed the files of the children and noticed that there were children missing LIC9224s that documented the two type A deficiencies that were cited within the last year signed and placed in the children's files. LPAs also noticed while reviewing children's files, there was one child who was missing their immunization's records within the file. Licensee attempted to locate the immunization records during the inspection, but was unsuccessful.

Three Type B Deficiencies are being cited based on LPAs' observation and interviews pursuant to Title 22 of the CA Code of Regulations and Health and Safety Requirements (refer to LIC 809-D). Licensee was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Erika Flores
SUPERVISORS NAME: Lissete Gonzalez
LICENSING EVALUATOR NAME: Aaliyah Zendejas
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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
Document Has Been Signed on 09/23/2024 12:09 PM - It Cannot Be Edited


Created By: Aaliyah Zendejas On 09/23/2024 at 11:14 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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
CCR
102418(g)

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102418 Immunizations (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. The requirement was not met as evidenced by:
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Licensee is to obtain written immunizations by parents or copy them on the immunizations form and have immunizations documented within the file.
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Based on record review, the licensee did not comply with the section cited above in which the LPAs noticed that the licensee was missing immunizations for some children in care to the which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/07/2024
Section Cited
CCR102416.3(a)

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102416.3 Alterations to Existing Buildings or Grounds(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including... This requirement was not met as evidenced by"
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Licensee is to submit a written plan regarding the construction that is currently taking place to the department.
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Based on observations and interview, the licensee did not comply with the section cited above in which the licensee did not notify the department regarding alertations made to the grounds which poses/posed 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:Lissete Gonzalez
LICENSING EVALUATOR NAME:Aaliyah Zendejas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/23/2024 12:09 PM - It Cannot Be Edited


Created By: Aaliyah Zendejas On 09/23/2024 at 11:22 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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
HSC
1596.8595(a)(1)

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ยง1596.8595 Posting licensing report by child care facility home...(a)(1) Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit... This requirement was not met as evidenced by:
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Licensee is to provide copies of the type A licensing reports to parents, have parents sign they have received the reports, and have these signed and placed within the children's files. Licensee is to also post the report and have it prominent at the entrance to the facility.
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Based on record review, the licensee did not comply with the section cited above in which the LPAs noticed licensee was not having parents sign the LIC9224s which poses/posed 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:Lissete Gonzalez
LICENSING EVALUATOR NAME:Aaliyah Zendejas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
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