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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274417590
Report Date: 12/28/2022
Date Signed: 12/28/2022 11:46:51 AM

Document Has Been Signed on 12/28/2022 11:46 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:IBARRA, LETICIAFACILITY NUMBER:
274417590
ADMINISTRATOR:LETICIA IBARRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 206-4584
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
12/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Leticia IbarraTIME COMPLETED:
12:00 PM
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On 12/28/2022 at 10:05 AM, Licensing Program Analyst (LPA) Susy Cervantes met with applicant, Leticia Ibarra, to conduct a pre-licensing visit. Applicant stated that the adults living in the home are themselves, their spouse, their son and daughter with one child age 11. Applicant owns the house. Applicant plans to get liability insurance and she understood that if she decides not to carry liability insurance in the future, she will have parent/authorized representative sign the Affidavit Regarding Liability Insurance for FCCH form (LIC 282).

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/28/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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.

The entire home was inspected for health and safety hazards. The home has a working dual smoke and carbon monoxide detector, a working telephone and a 3A40BC fire extinguishers that was fully charged. Certifications for CPR and First Aid expire 04/28/24. Preventative Health Practices training was complete on 11/19/22. Applicant has completed Mandated Reporter training on 03/29/2022. Immunizations for Measles, Pertussis, and influenza are on file for applicant.



Continues on report dated 12/28/2022 ______________________________ pg. 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: IBARRA, LETICIA
FACILITY NUMBER: 274417590
VISIT DATE: 12/28/2022
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Continuation of report dated 12/28/2022 ______________________________ pg. 2/3

Applicant stated that there are no weapons in the home. LPA observed two dogs and applicant stated they are vaccinated. LPA observed no fireplace, gated stairs and no bodies of water. Backyard is fenced. Off limit areas: second floor that has five bedrooms, two bathrooms, garage, storage room, and right side yard that will be fenced off. The days and hours of operation will be Monday through Sunday 23 hours a day. There were age appropriate toys in the childcare areas. Bathroom was clean.

Cleaning products, hazardous and sharp objects were inaccessible to children and stored in the garage and upstairs. Discipline policy was discussed with applicant and she understood that the children's personal rights should not be violated and corporal punishment is not allowed. Applicant stated that her discipline method will be talking to them. Applicant stated they will transport children; they understood the safety seat belt/car seat requirements.

A Family Child Care Home packet was reviewed with applicant. Department's website: www.ccld.ca.gov to obtain forms and regulations CCR, Title 22 was provided. Applicant was advised on the regulations that smoking, baby walkers, bouncers, excersaucers and other similar items are not allowed. The following was discussed, isolation of sick children; supervision of children; capacity options; requirements for reporting suspected child abuse; unusual incident/injuries; fire drills practiced at least twice a year and documented. LPA also discussed the requirements of AB 633 to applicant and provided applicant the fact sheet and a copy of Acknowledgement of receipt of Licensing Reports (LIC 9224). Zero Tolerance deficiencies with $500 civil penalty was also explained to applicant. 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.

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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: IBARRA, LETICIA
FACILITY NUMBER: 274417590
VISIT DATE: 12/28/2022
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Continuation of report dated 12/28/2022 ______________________________ pg. 3/3

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, Leticia Ibarra. LPA advised applicant that licensure for a large Family Child Care Home license is approved pending the following:

- Installation of the outdoor side gate
- Management's approval
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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