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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216652
Report Date: 07/24/2023
Date Signed: 07/24/2023 05:11:47 PM

Document Has Been Signed on 07/24/2023 05:11 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:ERNSTROM FAMILY CHILD CAREFACILITY NUMBER:
406216652
ADMINISTRATOR:JENNIFER ERNSTROMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 503-8486
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
07/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jennifer ErnstromTIME COMPLETED:
05:15 PM
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On 7/24/23, at 2:50 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an announced Prelicense Inspection of the abovementioned home and met with Applicant Jennifer Ernstrom. LPA informed Applicant of the nature and purpose of the inspection. Applicant informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from 9:00 AM--5:00 PM, Monday- Friday. Applicant also intends to care for children 2 years of age to 5 years of age. LPA informed Applicant the time of operation as well as the age of the children to be cared for can be modified with notification to CCLD. LPA notes, no children are in care at the time of the inspection.

LPA, in the company of Applicant, toured the interior and exterior of the home, in its entirety. The home is a five bedroom room, three bathroom two story dwelling. The home's living room, family room, dining room, front bathroom, and backyard will be used for child care services, while the the remainder of the home will be excluded. LPA observed child safety gates at the entry to the kitchen and in the hallway leading to the stairwell.

LPA observed the home to be clean and orderly. The home has spacing and ventilation for children in care. The home has no fireplace on the lower story. The bathroom to be used for children in care is observed to be clean and free of toxins. Sharps are stored in the kitchen which is excluded from care, while medication in the home is in areas which are accessible to children (i.e. elevated cabinets). Cleaning compounds are observed in the laundry room which is an area excluded from care. LPA observed a fire extinguisher (2A10BC) in the home which was serviced on 5/18/23. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has operable combination smoke/carbon monoxide detectors, one which were tested at 4:20 PM.

The backyard is enclosed by wooden fencing and the footing in the area is varied. The backyard's entry/exit gates are secured. There is reed fencing in the backyard which separated areas of child care from area of
(CONT. LIC 809-C, Page 2)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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: ERNSTROM FAMILY CHILD CARE
FACILITY NUMBER: 406216652
VISIT DATE: 07/24/2023
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personal use. There are two sheds in the backyard which are secure and contain household items. LPA observed a trampoline in the backyard. Applicant was reminded the trampoline should not be used for children in care. LPA observed on bodies of water on site.

LPA's record review revealed Applicants' Mandated Reporter training was completed on 5/23/23 (expiration 5/23/25), and Pediatric CPR/First Aid (EMSA approved) was completed on 4/3/23 (expiration 4/3/25). Applicant completed Preventative Health Training on 4/20/23. LPA reminded Applicant of obligation to maintain current training and certifications.

Because the Applicant leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149). Applicant does not have liability insurance for the home as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282). Applicant informed LPA no ammunition or firearms are on site.

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. Entrance Checklist was provided to the applicant.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02 CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
(CONT. LIC 809-C, Page 3)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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: ERNSTROM FAMILY CHILD CARE
FACILITY NUMBER: 406216652
VISIT DATE: 07/24/2023
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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-andresources/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.

On 7/24/23, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with the Applicant Jennifer Ernstrom. The home meets Title 22 Division 12 requirements of a Large FCCH License. Effective date of license will be noted as the present, 7/24/23.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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