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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216545
Report Date: 09/09/2025
Date Signed: 09/09/2025 02:32:13 PM

Document Has Been Signed on 09/09/2025 02:32 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:HERNANDEZ LEYVA FCCHFACILITY NUMBER:
426216545
ADMINISTRATOR/
DIRECTOR:		EMMA HERNANDEZ LEYVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 332-7563
CITY:GUADALUPESTATE: CAZIP CODE:
93434
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/09/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Emma Hernandez LeyvaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 9/9/25, at 12:45 PM, Licensing Program Analyst (LPA) Matthew Sapien conducted an unannounced annual random inspection visit of the abovementioned Family Child Care Home (FCCH). LPA met with Emma Hernandez Leyva, Licensee of the FCCH, and explained the nature and purpose of the inspection. The LPA, in the company of Licensee, toured the FCCH in its entirety. The home is a 3 bedroom and 2 bathroom single story home. The areas that are accessible for day care children are as follows: living room (main day care room), enclosed breezeway, hallway bathroom, and side patio. The remainder of the home is excluded from childcare services. Inaccessible rooms and areas are made secure by child safety knobs. At the time of the inspection, LPA observed 5 day care children present, two of which were infants. In addition to the Licensee, LPA also observed one assistant (Licensee's spouse) and one of the Licensee's children (underage) on site helping with the care and supervision of children (cleared and associated).

LPA observed the FCCH to be clean and orderly. The bathroom, utilized for childcare, is clean and free of toxins. LPA observed bathroom cabinets to contain child safety latches. LPA observed personal medications in an elevated kitchen cabinet. No children currently require medication. Primary cleaning solutions are stored in a couple of areas in the garage, an area that is inaccessible to day care children. Sharps are stored in a locked kitchen drawer.

LPA observed age-appropriate toys, furnishings, and equipment throughout the living room and in the breezeway. LPA observed no fireplaces in the residence. LPA observed a child safety gate separating the kitchen from the living room. Licensee informed LPA that there is one large dog present on site. Licensee informed LPA that the dog is vaccinated, however, the dog doesn't have interactions with children in care. LPA observed a First Aid Kit in the residence for the day care near the entryway of the residence.

LPA observed relevant licensing forms and documents posted prominently near doorway of the residence. (CONT. 809-C, Page 2)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HERNANDEZ LEYVA FCCH
FACILITY NUMBER: 426216545
VISIT DATE: 09/09/2025
NARRATIVE
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LPA observed a number of smoke and carbon monoxide detector within the household. The smoke detector was tested at 2:26 PM and the carbon monoxide detector was tested at 2:27 PM and each were found to be operational.

LPA observed a regulation fire extinguisher in the FCCH which was last purchased on 7/3/25. LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually. LPA reviewed the FCCH's fire/disaster drill log. The most recent disaster drill occurred on 9/9/25. LPA reminded the Licensee that disaster drills must be conducted every six months per Department regulations.

As aforementioned, a side patio in the backyard is accessible to children in care. The FCCH's outdoor area is enclosed by secure wooden fencing throughout. The fence’s entry/exit points are secure. As is the case with the interior of the FCCH, the outdoor area has age-appropriate play structures, toys, and other equipment throughout the area that can afford for robust childcare services. Licensee was reminded to replace toys and play equipment which start to degrade or are not in good repair. The footing of the exterior is made up of concrete pavement. Installed foam mats covering most of the concrete was also present. Shade is provided by the house itself. LPA also observed no bodies of water on site and confirmed that this was the case with the Licensee. The Licensee attested to LPA that children are always supervised when engaged in outside activity.



LPA reviewed children's records. The records are current, complete, and possessed emergency contact information and immunization records, among other relevant licensing documents and forms. The Licensee's records were also reviewed. LPA found that the Licensee completed their CPR/First Aid Training (EMSA approved) on 8/21/25 and their Mandated Reporter Training on 1/30/23. Licensee was reminded to renew certifications and training prior to expirations. The Licensee informed LPA that there are no firearms or ammunition that are stored on site.

The Licensee does not currently provide Incidental Medical Services (IMS) or administer medication to children in care. IMS policy was discussed. For IMS information see PIN 22-02CCP. 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 Family Child Care Homes and the ADA, available at: http://www.ada.gov/childqanda.htm. (CONT. 809-C, Page 3)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HERNANDEZ LEYVA FCCH
FACILITY NUMBER: 426216545
VISIT DATE: 09/09/2025
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LPA discussed the safe sleep regulations with Licensee 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 the Licensee of the importance of checking for recalled infantdevices 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.

Licensee 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.

During today's visit, one Type B citation was issued (see LIC 809-D page).

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility when the LPA completed an RSO profile in FAS on 9/9/25.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were also given and signature on this form acknowledges receipt of these rights. Exit interview was conducted and report was reviewed with the Licensee, Emma Hernandez Leyva.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 02:32 PM - It Cannot Be Edited


Created By: Matthew Sapien On 09/09/2025 at 02:03 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: HERNANDEZ LEYVA FCCH
FACILITY NUMBER: 426216545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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The Licensee will submit a copy of a renewal mandated reporter training certificate on or before 9/23/25 before the close of business day to the Department (matthew.sapien@dss.ca.gov)
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.
Maria Mueller
NAME OF LICENSING PROGRAM MANAGER:
Matthew Sapien
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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