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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216951
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:16:47 PM

Document Has Been Signed on 05/06/2024 01:16 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:HERNANDEZ-MEDINA FCC AKA LITTLE BLESSING DAYCAREFACILITY NUMBER:
406216951
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ-MEDINA, MAYRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 710-7489
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mayra Hernandez-MedinaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 5/6/24, at 10:15 AM, Licensing Program Analyst (LPA) Elvin Baddley conducted an announced Prelicense Inspection of the abovementioned residence and met with Applicant Mayra Hernandez-Medina. 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 6:00 AM--6:00 PM, Monday- Friday. Applicant also intends to care for children 0 years of age to 12 years of age. Applicant was informed changes in licensing hours and/or the ages of children supervised and cared for can be altered upon notifying CCLD of the given modifications and/or changes. LPA notes no children are on site at the time of the inspection.

LPA, in the company of Applicant, toured the interior and exterior of the residence in its entirety. The residence is a three bedroom and three bathroom two story dwelling. The area to be used for child care within the residence is the living room, dining room, first floor restroom and the side yard, while the reminder of the home is excluded from care. LPA observed child safety gates at the base of the stairwell, the entry to the kitchen and after the entry to the restroom. LPA notes the backyard of the residence is enclosed by fencing exceeding five feet and has a swimming pool in the rear. Children is care will have no access to the residence's backyard.

LPA observed a regulation fire extinguisher (2A10BC) in the area for child care which was serviced on 4/9/24 (expiration 4/9/25). LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The residence has multiple combination smoke/carbon monoxide detectors. A combination smoke/carbon monoxide detector in the dining room was tested at 10:55 AM and found to be operable.

LPA observed the residence to be clean and orderly. The residence has spacing and ventilation for children in care. The aforementioned has a fireplace in the living room which is screened by glass. The restroom to be used for children care is observed to be clean and free of toxins. Sharps and medications are located in kitchen area which is excluded from care. Clean compounds are located in the restroom and kitchen in (CONT. 809-C, Page 2)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSING DAYCARE
FACILITY NUMBER: 406216951
VISIT DATE: 05/06/2024
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 secure cabinets.

The side yard to be used by children is enclosed by wooden fencing. The footing in the area is grass. LPA observed no bodies of water in the side yard. As mentioned previously in the report, the residence's backyard has a swimming pool. The pool is enclosed in the residence's backyard by fencing which exceed five feet. The backyard area is secure. Children in care will be unable to access the residence's backyard. Further, LPA reminded the Applicant children in care are not to use the pool in the residence's backyard. LPA reminded the Applicant to ensure direct supervision of children in care when traveling beyond the property for outdoor activities. Additionally, LPA reminded Applicant to replace outdoor play equipment and toys when such items began to degrade or are not in good repair.

LPA's record review revealed Applicant's Mandated Reporter training was completed on 8/29/23 (expiration 8/29/25), and Pediatric CPR/First Aid (EMSA approved) was completed on 2/26/24 (expiration 2/26/26). Applicant completed Preventative Health Training on 10/26/23 and a CCLD orientation certification on was obtained on 10/26/23. LPA reminded Applicant of obligation to maintain current training and certifications.
Because the Applicant rents/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 and firearms are on site. LPA observed one dog on site. Applicant informed LPA dog while not have access to children (and vis versa).

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.

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.



LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep

(CONT. 809-C, Page 2)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSING DAYCARE
FACILITY NUMBER: 406216951
VISIT DATE: 05/06/2024
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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 of infant devices or their purchased equipment.

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.



On this date, 4/4/24, 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 address. 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.

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.

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.


(CONT. 809-C, Page 4)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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: HERNANDEZ-MEDINA FCC AKA LITTLE BLESSING DAYCARE
FACILITY NUMBER: 406216951
VISIT DATE: 05/06/2024
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Exit interview conducted and report was reviewed with the Applicant Mayra Hernandez-Medina. The home does meets Title 22 Division 12 requirements of a FCCH License at this time. Given Applicant prior experience with an infant and preschool program which exceeds a year, Applicant is granted licensure for a FCCH of 14, with an effective date 5/6/24.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4