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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216170
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:05:19 PM

Document Has Been Signed on 11/17/2021 02:05 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:VILLA FCC AKA KIDDOS KLUBHOUSEFACILITY NUMBER:
406216170
ADMINISTRATOR:MARTHA VILLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 286-7895
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/17/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Martha Villa TIME COMPLETED:
02:10 PM
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On 11/17/21 at 1:30 PM, an office meeting was held at the Santa Barbara Regional Office for the purpose of conducting an informal conference. Present at the meeting were Licensing Program Manager Maria Mueller, Licensing Program Analyst Francisca Velazquez, and Applicant Martha Villa.

The purpose of the informal conference was to discuss the signed order on
August 22, 2012, Decision and Order for the previous licensed facility owned by applicant facility # 406208170.

The FCCH’s 406208170 Revocation of the license was STAYED, for four (4) years during which time the Martha Villa was granted a probationary license subject to the following limitations and conditions:

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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 4
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: VILLA FCC AKA KIDDOS KLUBHOUSE
FACILITY NUMBER: 406216170
VISIT DATE: 11/17/2021
NARRATIVE
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· Martha Villa agreed to operate the facility in strict compliance with
the regulations and statutes governing the operation of a family child care home.
· During the period of probation, the Department in its sole discretion
may conduct unannounced site visits for the purpose of determining whether there is full compliance with the regulations and statutes governing the operation of a family child care home.
· Martha Villa shall ensure that poisons, detergents, cleaning
compounds and other toxic products that could pose a danger to children are stored in a locked place where they are not accessible to children.
· Martha Villa shall reduce her facility capacity to eight (8) day care children from fourteen (14) day care children.
· Martha Villa shall not provide care to special needs children.
· Martha Villa shall not provide care to infants, defined as children
under the age of two (2) years.
· Martha Villa shall have at least two (2) adults providing care and
supervision to day care children at all times.
· Martha Villa shall install a video camera in the back of the facility to monitor the back yard in order to provide proper and adequate care and supervision while day care children are playing in the backyard.
· Martha Villa shall report to the Licensing office the following: any unusual incident including, but not limited to, client death or injury which requires medical treatment, any suspected physical or psychological abuse of any client, any physical plant changes and all unexplained absences. These incidents must be reported by the next working day, and a written report of the incident must be submitted within seven days following the occurrence of the incident. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: VILLA FCC AKA KIDDOS KLUBHOUSE
FACILITY NUMBER: 406216170
VISIT DATE: 11/17/2021
NARRATIVE
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· Within ninety (90) days from the effective date of this Stipulation, Martha Villa shall take a course in the proper care and supervision of children that is approved by the Department.
· Martha Villa shall install a safety lock on the bathroom door of the master bedroom.
· Martha Villa shall ensure that the facility is clean, safe, sanitary and in good repair, at all times for the safety and well-being of clients, employees and visitors.

The following was discussed and the applicant has agreed to the following from today’s office conference;

· Martha Villa shall submit a copy of the training regarding Proper Care and Supervision.
· Martha Villa shall submit a written statement indicating how children's personal rights will not be violated at any time.
· Martha Villa’s Probationary license will be 3 years and 2 months from the date she will be licensed.
Increased unannounced visits to the facility will be made for the next three years to monitor compliance.
Martha Villa was informed that any additional Type A deficiencies may result in a more immediate administrative action against the License.

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: VILLA FCC AKA KIDDOS KLUBHOUSE
FACILITY NUMBER: 406216170
VISIT DATE: 11/17/2021
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Upon receipt, Martha Villa shall provide copies of this licensing report to parents/guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. The Acknowledgement of Receipt (LIC 9224) to parents shall be completed and signed by each parent/guardian with copies maintained in each child's file. Licensee was given a copy of LIC 9224 Acknowledgement of Receipt of Licensing Reports.

Completion of probation: If Respondent has successfully complied with the terms of this Stipulation, at the end of four (4) years from the effective date, the condition imposed upon Respondent's license will expire and Respondent's license shall be granted or restored in full.

Applicant verbally agreed to all stipulations stated during today's meeting.

This meeting was translated in Spanish to Applicant Martha Villa by LPA Velazquez, due to Spanish being the primarily language of the Applicant.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4