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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215775
Report Date: 07/20/2021
Date Signed: 07/20/2021 01:30:35 PM

Document Has Been Signed on 07/20/2021 01:30 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:CASEY-LOPEZ FCC AKA CAMPANITA DAYCAREFACILITY NUMBER:
566215775
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dolores LopezTIME COMPLETED:
01:40 PM
NARRATIVE
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On July 20, 2021 at 10:30 AM Licensing Program Analyst (LPA) Laura Villanueva conducted an unannounced inspection to complete a Required - 1 Year visit. LPA met with Licensee, Dolores Lopez. Due to COVID-19 pandemic, LPA asked the pre screening questions, Licensee's responses indicate no COVID-19 exposure on site. LPA toured home inside and outside with Licensee. The facility is a 3 bedroom 2 bathroom 1 story home. The Licensee will use the one bedroom, living room, kitchen and one bathroom for the child care. LPA reminded Licensee that rooms that are off limits to child care children need to be made inaccessible by lock or barrier. Licensee stated that she normally has a gate in the hallway to the bedrooms and bathroom that are off limits to the children. Licensee will ensure the gate is in place prior to children being present in the home.

There are age appropriate toys and equipment. LPA did not observe any toxins/hazardous items accessible to children. LPA did not observe any bodies of water. The regulation 2A10BC fire extinguisher was serviced on 11/19/20. Applicant is reminded to service or purchase the fire extinguisher yearly. The combination smoke/carbon monoxide detector was observed on the ceiling in the living room. Licensee's Pediatric First Aid/CPR certificate was valid until 2/16/2019. Licensee will need to renew certificate and submit proof to the Department. Licensee states that there are no guns/weapons on the premises.

LPA reviewed child files. They contained documentation for subsidized child care with no licensing required forms completed. LPA discussed with and gave Licensee a packet of updated samples of state required forms to be kept in the children's file, required forms to be posted and forms that needs to be maintained at the FCCH. Licensee will be completing required licensing forms with parents and placing a copy of the immunization card for the children who do not attend school. LPA also provided Applicant with immunization cards (blue cards), safe sleep pamphlet, and LIC9227 Individual Infant Sleep Plan. Licensee has not completed any fire drills with the children since she has been licensed. LPA provided licensee with a sample form to document fire drills

Continued on LIC809C
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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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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: CASEY-LOPEZ FCC AKA CAMPANITA DAYCARE
FACILITY NUMBER: 566215775
VISIT DATE: 07/20/2021
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes 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

LPA reviewed SB 792 the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, and Measles. LPA advised the Flu Vaccine may be completed yearly between August 1 - December 1, or complete a waiver.

Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov. Also, Licensee was reminded that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22. See attached LIC809D.



An exit interview was conducted and plans of corrections were developed and reviewed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Dolores Lopez, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2021 01:30 PM - It Cannot Be Edited


Created By: Laura Villanueva On 07/20/2021 at 12:18 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: CASEY-LOPEZ FCC AKA CAMPANITA DAYCARE
FACILITY NUMBER: 566215775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2021
Section Cited
CCR
102417(g)(9)(A)(1)

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102417 Operation of a Family Child Care Home
(g) The home shall be free...Safety precautions shall include but not be limited to: Each family child care home shall have... duties as required in the plan. (A) Each family child care home shall ... once every six months.
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Licensee will conduct a fire drill with the children by 7/21/21 and submit written proof to the Department. LPA provided Licensee with a sanple Fire Drill log to use.
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1.The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.
This requirement was not met as evidenced by Licensee has never conducted a fire drill with the children.
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Type B
07/20/2021
Section Cited
CCR102416(c)

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102416 (c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete... pursuant to Health and Safety Code Section 1596.866.This requirement was not met as evidenced by: Licensee's Pediatric CPR/First Aid certificate expired 2/16/19.
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Licensee shall complete an in person Pediatric CPR/First Aid Class and submit proof to the Department by 8/3/21.
Type B
07/20/2021
Section Cited
CCR
102418(g)(1)

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102418
Immunizations -(g) The licensee shall document each child's immunizations...as long as the child is enrolled.(1) This requirement includes updating each child's...family day care home. This requirement was not met as evidenced by: Child files did not contain licensing forms.
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LPA reviewed and provided Licensee with required forms to keep in each child's file. Licensee will have parents complete forms packet by 7/22/21 and submit proof of correction to the Department.
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:George Mingle
LICENSING EVALUATOR NAME:Laura Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021


LIC809 (FAS) - (06/04)
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