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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216032
Report Date: 12/02/2021
Date Signed: 12/09/2021 12:11:37 PM

Document Has Been Signed on 12/09/2021 12:11 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:CERPAS FCC AKA KID CITY DAYCAREFACILITY NUMBER:
426216032
ADMINISTRATOR:ANNETTE CERPASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 314-5298
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Sulema MejiaTIME COMPLETED:
06:00 PM
NARRATIVE
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On December 2, 2021 @ 10:25 AM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced 1 Year Required Inspection. Prior to entering the facility, LPA conducted COVID-19 pre-screening questionnaire and based on responses it was determined that the facility is safe and free of any COVID-19 exposures. LPA met with Assistant, Sulema Mejia and discussed the purpose of the inspection. Assistant notified LPA that Licensee is out of town and is not available for inspection. Assistant provided LPA with a tour of the facility inside and out. There were nine (9 ) children and two (2) adults total present during the inspection.

LPA verified that S2 is not fingerprint cleared nor associated to the facility. Per assistant, today is S2's first day at the facility. During file review, LPA observed S2 did not have a file for review.

During the tour LPA observed the following, required forms are posted in the prominent location. At 12:04 PM, LPA observed that chimney screen in the play area was not locked and accessible to children in care. At 12:05 PM, LPA observed toxins and cleaning supplies located in the lower cabinet of the children restroom accessible to children in care. Restroom cabinets did not have safety locks. At 12:10 PM, LPA observed the fire extinguisher expired on 5/7/21. LPA observed knife in the kitchen counter and adult size scissors in the dinning room table. At 12:14 PM smoke and carbon monoxide detectors were tested and found functional. LPA observed the home to be clean with age appropriate toys. The outside play area is an open space and is completely fenced. Licensee was reminded that visual and physical supervision is required when day care children are outside. No bodies of water was observed. Assistant stated there are no guns and ammunition in the home. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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Document Has Been Signed on 12/09/2021 12:11 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/02/2021 at 04:50 PM
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in one out of the two staff members present is not fingerprint cleared or associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Licensee will ensure that all adults working or residing in the home are fingerprint clear prior to being in the facility. Licensee will ensure S2 is not present until S2 receives fingerprint clearance.
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with assistant and record review, the licensee did not comply with the section cited above as LPA observed nine (9) children present with one staff supervising. All children were younger than 4 years old which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Licensee will ensure that when one adult is present at the facility, the facility will only operate as a Small FCCH. Licensee will submit a plan of correction detailing how she will ensure that the facility does not have more children present than allowed.
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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 12/09/2021 12:11 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/02/2021 at 04:50 PM
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to having had nine (9) children being supervised by one (1) adult. All children were younger than 4 years of age which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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Licensee will submit a plan to the department detailing how she will ensure that there is never more than 8 children when one adult is present in the facility. Licensee will also ensure that age requirements are met when all eight (8) children are present.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/09/2021 12:11 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/02/2021 at 04:50 PM
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there was a knife in the kitchen counter and adult size sciccors in the dinning room table asseccible to children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee will ensure all sharps are stored in an area that are out of the reach of children. Licensee to submit photograph showing sharps are out of the reach of children in care.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to the last emergency drill was conducted on 4/20/21 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee will conduct an emergency drill, document it and send LPA a photograph. Licensee to create a plan to ensure that emergency drills are conducted and documented every six (6) months.
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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2021 12:11 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/02/2021 at 04:50 PM
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to not having a staff file for S2. LPA observed that S1 file only contained TB clearance and required immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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Licensee will create files for S1 and S2 and ensure that all required documents are availble for review during inspections. Licensee to email all staff documents to LPA by 12/9/21.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that S2 does not have any immunizations on file or TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2021
Plan of Correction
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LIcensee will created Staff files and will ensure that every file has required immunizations and TB clearance.
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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/09/2021 12:11 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/02/2021 at 04:50 PM
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to C3, C6, and C9 did not have immunization record or bluc card on file for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Licensee will review all children file and will update all missing immunizations. Licensee to send LPA a photograph showing all updated immunizations.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021


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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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032
VISIT DATE: 12/02/2021
NARRATIVE
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LPA reviewed the following documents, Pediatric CPR and First Aid Card for assistant expires 7/12/22. Assistant completed the Mandated Reporter Training on 8/29/2020. Assistant's immunization record is complete per SB 792. Fire and Disaster drill was not conducted and logged within the last 6 months. LPA reminded Licensee fire and disaster drill should be conducted and logged every 6 months. Children’s roster is available and current. All children present during today's inspection were documented in the facility roster.

LPA reviewed children and staff records. The children records were found to be incomplete as C3, C6 and C9 did not have immunization record or blue card available for review. LPA reviewed staff files and found S1 only has TB clearance and required immunization's and S2 did not have a file at all in the facility.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home Section 102417. 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) / (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.


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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: CERPAS FCC AKA KID CITY DAYCARE
FACILITY NUMBER: 426216032
VISIT DATE: 12/02/2021
NARRATIVE
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LPA discussed current Safe Sleep and Covid-19 requirements with Assistant. LPA provided copy of safe sleep regulation for Licensee and Assistant to review. Assistant 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.

During today's inspection deficiencies were cited under California Code of Regulation Title 22 Division 12. Deficiencies are documented under LIC 809 D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Assistant.

LPA left the facility without signature due to computer being on consistency mode. LPA returned to the facility on 12/9/21 and reviewed report with Licensee, Annette Cerpas. LPA gathered signatures of reports and provided appeal rights.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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