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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215193
Report Date: 06/28/2023
Date Signed: 06/28/2023 06:58:47 PM

Document Has Been Signed on 06/28/2023 06:58 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
CENTRAL COAST-CHILD, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SHEA FAMILY CHILD CAREFACILITY NUMBER:
566215193
ADMINISTRATOR:ANA VICTORIA SHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 300-7432
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:46 PM
MET WITH:Patricia Estacio JimenezTIME COMPLETED:
07:15 PM
NARRATIVE
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On June 28, 2023 at 4:30PM Licensing Program Analysts (LPAs) Giovani Gonzalez and Elvin Baddley conducted and unannounced Case Management Inspection at the above-mentioned Family Child Care Home (FCCH). LPAs met with Patricia Estacio Jimenez, assistant of the FCCH and informed her the nature of todays inspection. At the time of inspection there were 3 children and 1 other assistant (A1).

At approximately 4:40PM assistant Patrcia Estacio Jimenez informed LPAs that Licensee Ana Victoria Shea is on a vacation in Central America. Assistant also stated that Licensee left at approximately 10:30am 6/28/23 and that they would return the week of 07/03/23. LPAs explained that regulation pertaining the Licensee's temporary absences from the FCCH not exceed 20 percent of the hours that the facility is providing care per day.

A file review revealed that A1 does not have current Mandated Reporter Training (AB1207). LPAs asked A1 if they had taken the Mandated Reporter Training. A1 stated that they do not remember taking that class.

Two Type B Deficiencies were issued based on assistant interviews and record review pursuant to Title 22 of the CA Code of Regulations (refer to LIC 9102). Assistant was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.

Appeal Rights and Notice of Site Visit was given.

Exit interview was conducted with Patricia Estacio Jimenez.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Giovani Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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Document Has Been Signed on 06/28/2023 06:58 PM - It Cannot Be Edited


Created By: Giovani Gonzalez On 06/28/2023 at 06:05 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: SHEA FAMILY CHILD CARE
FACILITY NUMBER: 566215193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
102417(a)

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(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. ... Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
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Licensee to provide a written plan explaining how Licensee's absences will not exceed 20 percent of the hours that the FCCH is providing care per day. Written plan to be provided to CCLD (giovani.gonzalez@dss.ca.gov) by 7/12/23.
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Based on observations and interview, the licensee did not comply with the section cited above as Licensee is away from the FCCH in excess of 20 percent of the hours that the facility is providing day care on 6/28/23 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/12/2023
Section Cited
HSC1596.8662(b)(1)

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(1) On ...employee of a licensed child day care facility shall complete the mandated reporter training provided ... 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:
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Licensee to complete Mandated Reporter Training and submit certification of completion to CCLD (giovani.gonzalez@dss.ca.gov) no later than 7/12/23.
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Based on observation, interview and record review, the licensee did not comply with the section cited above as A1 did not have Mandated Reporter Training (AB1207).
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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:Ana Tolentino
LICENSING EVALUATOR NAME:Giovani Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023


LIC809 (FAS) - (06/04)
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