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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216213
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:22:11 PM

Document Has Been Signed on 09/12/2024 05:22 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: 4DATE:
09/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Erika FloresTIME VISIT/
INSPECTION COMPLETED:
05:36 PM
NARRATIVE
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On September 12, 2024, Licensing Program Analyst's (LPA's) Susana Martinez and David Roman conducted an unannounced Case Management- Deficiencies inspection. LPA's met with Licensee, Erika Flores and advised her of the purpose for the inspection. Together with the Licensee, LPA's toured the facility inside and outside. At the time of inspection there was one child in care and three adults. During the inspection Licensee stepped out to pick up children from school. By the end of the inspection there were 4 children in care.

The Department conducted an annual inspection on 04/29/24 where multiple deficiencies were issued, which included:
- CCR102425(b) for objects in a crib.
- CCR102425(j)(2) for 15 minute safe sleep checks.
- HSC1597.622(c) for missing assistants immunization records.

During today's inspection LPA's observed mobiles hanging from two (2) play pens where infants are placed to sleep. Although there were no infants in care, LPA's reminded Licensee that mobiles are not allowed to be placed on the crib/play pen. Licensee states she currently has three (3) infants (C1, C2, and C3) enrolled. During the inspection LPA's asked the Licensee when the infants were last in care, Licensee states the infants were last in care on 09/09/24 and 09/10/24. LPA's reviewed the infant safe sleep logs and observed three (3) out of three (3) infant safe sleep logs to be incomplete. LPA's observed C1's safe sleep to be noted last on 09/04/24. Licensee could not provide LPA's with proof of safe sleep documentation for 09/09/24, which was the last date C1 was in care. LPA's educated Licensee on how to properly document Safe Sleep Log.


Continued on 809-C
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/12/2024 05:22 PM - It Cannot Be Edited


Created By: Susana Martinez On 09/12/2024 at 02:14 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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
102425(j)(2)

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102425(j)(2)The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
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Licensee is to submit proof of safe sleep checks for the next two week to the Department. LPA's provided a Spanish safe sleep check template to Licensee. Licensee will be invited to an in office meeting at a later time.
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Based on observation and record review, the licensee did not comply with the section cited above in which there were no documentation of safe sleep checks being done which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/26/2024
Section Cited
CCR102425(b)

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102425(b)Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
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Licensee it to submit proof of removal of the objects hanging from the play pen. The Licensee will be invited to an in office meeting at a later time.
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Based on observation, the licensee did not comply with the section cited above in one infant was found in the play pen with multiple objects within the crib, which poses an immediate 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:Ana Tolentino
LICENSING EVALUATOR NAME:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213
VISIT DATE: 09/12/2024
NARRATIVE
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The Department received a complaint on 04/30/24 in which the Department conducted an investigation which included interviews, record reviews and observations which revealed information of an uncleared adult living in the home. LPA's obtained sufficient information through interviews and observations. Based on LPA's observations, interviews which were conducted, documents gathered and/or record reviews, the preponderance of evidence standard has been met.

LPA's asked Licensee who lives in the shed located in the backyard. Licensee states her adult daughter (A1) stays in the home. LPA's asked for Licensee to open the shed to confirm. Licensee stated she did not have the keys. When A1 arrived to the facility, LPA's asked for her to open the shed to which she responded "I do not have the keys". A1 stated she stays in the shed on occasion, but lost the keys. LPA handed A1 a declaration form (LIC855) to put her statement in writing.

Licensee certifies that no one else lives in the home. LPA's advised Licensee that the Department has sufficient information to determine that the person who lives in the shed is not her adult daughter A1. LPA's asked Licensee to write a Declaration on LIC855 (SP- in Spanish). Licensee insisted that she did not have access to the shed.

During today's inspection two type A deficiency for conduct inimical and 3 type B citations for four repeat violations along with civil penalties.

LPA's S. Martinez and D. Roman informed Licensee, Erika Flores that this report dated 09/12/24 document(s) two Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA S. Martinez informed the Licensee, Erika Flores to provide a copy of this licensing report dated 9/12/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Continued on 809-C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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Document Has Been Signed on 09/12/2024 05:22 PM - It Cannot Be Edited


Created By: Susana Martinez On 09/12/2024 at 03:18 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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2024
Section Cited
HSC
1597.622(c)

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1597.622(c)(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.This requirement is not met as evidenced by:
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Licensee is to submit Assistants proof of immunization records to LPA's by 09/16/2024. Licensee will be invited to an in office meeting at a later time.
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Based on record review, the licensee did not comply with the section cited above in which the LPAs did not see any immunizations for the assistant to the 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:Ana Tolentino
LICENSING EVALUATOR NAME:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213
VISIT DATE: 09/12/2024
NARRATIVE
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At 4:11 PM, Licensee opened up the shed for LPA's to view. Licensee states she randomly found the keys. LPA's entered the shed and noted the observations.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with Licensee, Erika Flores.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Susana Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/12/2024 05:22 PM - It Cannot Be Edited


Created By: Susana Martinez On 09/12/2024 at 04:06 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: FLORES FCC AKA KOODAKAN DAYCARE
FACILITY NUMBER: 566216213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
HSC
1596.885(c)

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1596.885(c)Denial, suspension or revocation of license, registration, or special permits; grounds(c)(c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state. This requirement was not met as evidence by:
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The Licesnee will be invited to the SBRO for an in office confrence at a later time.
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Based on observations and interviews, the licensee did not comply with the section cited above in which the Licensee did not comply with LPA's when questioned on adults living in the shed which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/12/2024
Section Cited
CCR102370(a)

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102370 Criminal Record Clearance (a) Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. This requirement was not met as evidence by:
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The Licesnee will be invited to the SBRO for an in office confrence at a later time.
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Based on LPAs observations, interviews, and record review, the licensee did not comply with the section cited above as an adult living in the home failed to conduct a criminal record clearance which poses/posed an immediatel 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:Ana Tolentino
LICENSING EVALUATOR NAME:Susana Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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