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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566215775
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:43:44 PM

Document Has Been Signed on 05/17/2024 04:43 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/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Dolores Lopez & Isabel Felix TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On May 17, 2024 at 2:35 PM, Licensing Program Analyst (LPA) Laura Villanueva made an unannounced visit to conduct an Annual/Random Inspection. LPA met with licensee, Dolores and Assistant, Isabel Felix and explained the purpose of the inspection. LPA toured the interior and exterior of the home while waiting for Licensee. Assistant was caring for 2 children at the time of the inspection. Licensee arrived with 2 school aged children.

The home is a 4-bedroom, 2-bath, 1- story home. The licensee uses the playroom, living room, dining area, kitchen, one bathroom and the backyard for childcare. The 3- bedrooms, 1-bathroom, and garage are off limits and are inaccessible to children in care. LPA observed a screened fireplace in the living room making it inaccessible to children in care. Licensee has a secured fence in the backyard. LPA observed toxins/hazardous items on sink accessible to children in the bathroom. A regulation 2A10BC fire extinguisher was observed mounted in the dining area with a service date of 04/20/2024. Licensee is reminded to service or purchase the fire extinguisher yearly. Licensee states that there are no firearms and ammunition in the home. A container with water was observed by the garage next to the walk way to the front door. Licensee dumped water out in LPA's presence. LPA observed a baby bouncer in the living room. LPA informed that Licensee that bouncers are not allowed in the child care. Licensee removed bouncer in LPA's presence.

Licensee's Pediatric First Aid/CPR certificate is valid until 09/18/25. AB 1207 Mandated Reporter Training certificate is valid until 01/10/2026. Licensee last completed an emergency disaster drill on 01/24/2024. All required forms including Notification of Parent's Rights are prominently posted for parent's or authorized representatives to view. A roster of children in care was observed current and complete. All children records were reviewed, and LPA did not observe files containing Identification and Emergency Notification forms (LIC 700) and a required forms for C3 & C4.

CONTINUED ON 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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: 05/17/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process

Licensee was reminded that all adults 18 and over living or working in the home, 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.


Licensee's Assistant has not obtained a criminal record clearance to work at the child care. Licensee informed LPA that fingerprints have not been completed.

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)/ (800) 514-0383
(TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the
ADA, available at: https://www.ada.gov/resources/child-care-centers/.

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-andresources/
safe-sleep as an additional resource. LPA also informed licensee [or facility
representative] 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 on
their purchased equipment.

CONTINUED ON LIC809

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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: 05/17/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; 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.

During the exit interview, the LICENSEE, Dolores Lopez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Today, Type A and Type B deficiencies are being cited under Title 22 Division 12 Appeal rights given. Civil penalty was assessed. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report

Exit interview conducted and report was reviewed with the licensee, Dolores Lopez. Visit was conducted in Spanish.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Laura Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/17/2024 04:43 PM - It Cannot Be Edited


Created By: Laura Villanueva On 05/17/2024 at 03:39 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee will have daughter in law/assistant get fingerprinted immediately. LPA provided fingerprint clerance form LIC9163
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:George Mingle
LICENSING EVALUATOR NAME:Laura Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2024 04:43 PM - It Cannot Be Edited


Created By: Laura Villanueva On 05/17/2024 at 03:39 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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Licensee will give C3 & C4 parents enrollment packet to complete. Licensee will email proof of correction via email to LPA at:laura.villanueva20@roadrunner.com
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:George Mingle
LICENSING EVALUATOR NAME:Laura Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/17/2024 04:43 PM - It Cannot Be Edited


Created By: Laura Villanueva On 05/17/2024 at 03:41 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to 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 in total count] of objects in the children's bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee removed toxins in LPA's presence.
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:George Mingle
LICENSING EVALUATOR NAME:Laura Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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