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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216315
Report Date: 09/09/2022
Date Signed: 09/13/2022 12:16:40 PM

Document Has Been Signed on 09/13/2022 12:16 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:PENA FCC AKA JAVI AND ALI FAMILY CHILD CAREFACILITY NUMBER:
426216315
ADMINISTRATOR:KARINA B. PENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 720-0517
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Karina Pena TIME COMPLETED:
12:30 PM
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On 9/9/22, at 9:30 AM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an announced Prelicensing Inspection of the abovementioned home and met with Applicant, Karina Pena. LPA informed Applicant of the nature and purpose of the inspection. LPA notes there are no children on site at the time of the inspection. Applicant informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from, Monday- Friday from 5:00 AM to 11:00 PM and Saturday from 5:00 AM to 5:00 PM. The Applicant also Informed LPA of the intention to provide care for children birth to 12 years of age.

LPA toured the interior and exterior of the home with the Applicant. This is a single level, four (4) bedroom home with two (2) bathrooms. The home's living room, one (1) bathroom in the hallway and part of the outdoor yard will be used for childcare services. Off limit areas includes; all four (4) bedrooms and one (1) bathroom, laundry room, garage and part of the back yard. LPA observed the living room to have ample spacing and ventilation for children in care. LPA observed a fireplace in the day-care room that is made inaccessible with a baby gate and diaper changing table. The home's bathroom to be used for children care is observed to be clean and free of toxins. LPA observed sharps and medication are stored in an elevated cabinet in the kitchen that is inaccessible to children in care. Cleaning compounds were observed in the laundry room and garage, both areas are inaccessible to children in care. LPA observed two gates making all off-limit areas inaccessible.

LPA observed a required fire extinguisher 2A10BC in the home which was purchased on 4/29/22. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has smoke and carbon monoxide detectors which were tested at 10:12 AM and found to be operable.

LPA observe the outdoor yard to be completely fenced. LPA observed the home provides natural shading and Applicant stated a canopy will also be added to provide more shade. Applicant reported water will be accessible by individual water cups. LPA observed part of the yard is made inaccessible by means of a gate. LPA notes no bodies of water were observed. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PENA FCC AKA JAVI AND ALI FAMILY CHILD CARE
FACILITY NUMBER: 426216315
VISIT DATE: 09/09/2022
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LPA record review revealed Applicant completed Preventative Health training on 2/22/22. Further, Applicant completed Mandated Reporter training on 7/29/22, and Pediatric CPR/First Aid (EMSA approved) on 7/31/22. LPA reminded Applicant of obligation to maintain current training and certifications. LPA reviewed Applicant's control of property document (Lease Agreement). Applicant does not have liability insurance for the home as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282). Applicant received fire clearance for a large license from Santa Maria Fire Department on 7/5/22.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 Applicant 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.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Karina Pena. The home meets Title 22 Division 12 requirements of a large FCCH license. Effective date of license will be noted as the present, 9/9/22/22. Today's inspection and review of report was conducted in Spanish due to Spanish being the Applicant's primary large.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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