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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216206
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:13:08 PM

Document Has Been Signed on 06/21/2022 12:13 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:SMITH FAMILY CHILD CAREFACILITY NUMBER:
426216206
ADMINISTRATOR:MELISSA SMITHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 268-8500
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
06/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Melissa Smith TIME COMPLETED:
12:15 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 6/21/2022, 10:41 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection. LPA met with Licensee, Ms. Melissa Smith LPA asked pre screening questions related to COVID-19, responses indicate there are no COVID -19 exposure on site. When LPA arrived, LPA observed 8 children and 4 staff present including the licensee.

During Facility Personnel Report review, LPA observed that Staff Alexis Rivas's Criminal Record Clearance is not associated to FCCH. Staff 1 stated she started working in FCCH on April 18, 2022. Licensee stated that transfer documents of Staff 1 were sent via mail and email, however, there was no confirmation of receipt and there was no mail/email verification.

During today's inspection, Type A deficiency was cited under Title 22 Division 12.
LPA Reyes informed licensee Ms. Smith that this report dated 6/21/2022 documents one (1) Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Also, LPA Reyes informed the licensee, Ms. Smith to provide a copy of this licensing report dated 6/21/2022 that documents any Type A citation 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.

Continued LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 426216206
VISIT DATE: 06/21/2022
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
A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee 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.

Notice of Site Visit was posted. Exist interview conducted and report was reviewed with Licensee, Ms. Melissa Smith.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/21/2022 12:13 PM - It Cannot Be Edited


Created By: Gigi Reyes On 06/21/2022 at 10:58 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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 426216206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited
CCR
102370(d)(2)

1
2
3
4
5
6
7
d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or
This requirment was not met as evidenced by:
1
2
3
4
5
6
7
During the inspection on 6/21/2022 Licensee forwarded the transfer documents of Alexis Rivas and on the same day, staff 1 criminal record was transferred and asosciated.
8
9
10
11
12
13
14
During the review of facility personnel report, it was observed that Staff, Alexis Rivas' criminal record clearance is not associated to the FCCH. MS. Rivas started working on 4/18/2022. This poses an immediate risk to health and safety of children in care.
8
9
10
11
12
13
14
 Liscensee shall send a written POC to CCL no later than 6/22/2022 on how to ensure that all staff are associated prior to employment.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Maria Mueller
LICENSING EVALUATOR NAME:Gigi Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


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