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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216070
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:17:23 PM

Document Has Been Signed on 05/19/2022 12:17 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:BERNAL FAMILY CHILD CAREFACILITY NUMBER:
566216070
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Martha BernalTIME COMPLETED:
12:35 PM
NARRATIVE
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On May 19, 2022 at 9:30 AM, Licensing Program Analyst (LPA) Betzayra Cervantes made an unannounced visit to conduct a Required - 1 Year inspection. LPA met with licensee, Martha Bernal and explained the purpose of the inspection. LPA conducted a COVID-19 risk assessment. All answers indicated no exposure to COVID-19. LPA in the company of the licensee toured the interior and exterior of the facility. Upon arrival to the home at 9:30AM, Licensee Martha Bernal was providing care to 8 children (2 infants, and 6 children 3 - 4 years old). LPA advised licensee in order to provide care to 8 children two of the children may be infants, however, two children need to be attending school/school age children.

The home is a three bedroom, two bath single story home. The licensee uses the den which is the main day-care area, living room, dining room, kitchen, one bathroom, and the backyard for day-care. The three bedrooms, one bathroom, garage are off limits and are inaccessible to children in care. LPA observed a screened fireplace in the family room which is inaccessible to children. LPA observed age appropriate toys, teaching materials and furnishings in good condition and free of hazards. All adults in the home are fingerprint cleared. LPA did not observe any toxins/hazardous items accessible to children. At 9:40AM, LPA observed a 2A10BC fire extinguisher mounted in the playroom. LPA did not observe a service tag or proof of purchase. Licensee stated that she could not locate the receipt. The last documented proof of purchase was on 2/8/2021. Licensee has a secured fence in the backyard and age appropriate toys for children in care, found in good condition and free of hazards. LPA observed a secured storage shed located in the sideyard which is inaccessible to children in care.

LPA observed the home to be orderly. No bodies of water were observed on site. No toxins nor hazards are accessible to children in care. Detergents and cleaning compounds are stored out of reach of children. The bathroom to be used for children in care was observed to be clean and sanitary. LPA had licensee test the smoke and carbon monoxide detectors in the home which were found operational.

CONTINUED ON 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 566216070
VISIT DATE: 05/19/2022
NARRATIVE
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During file review, LPA observed licensee's mandated reporter certificate with an expiration date of 4/29/2021 and Pediatric CPR and Fist Aid certification which expired on 2/11/2022. Licensee stated that she has not renewed her certification for both mandated reporter and Pediatric CPR and Fist Aid. 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. A sampling of children records were reviewed and are current and complete.

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

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/inspection-process.

Licensee 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.

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 licensee 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 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 566216070
VISIT DATE: 05/19/2022
NARRATIVE
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Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, refer to LIC809Ds. Licensee Shall provide parents with a copy of the The Type A violation and obtain the parent's signature on the LIC9224.

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee Martha Bernal. A copy of this report and appeal rights were discussed and left with licensee.

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

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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Document Has Been Signed on 05/19/2022 12:17 PM - It Cannot Be Edited


Created By: Betzayra Cervantes On 05/19/2022 at 11:29 AM
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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 566216070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(3)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (3) More than six and up to eight children, without an additional adult attendant, only if the criteria in
Section 1597.44 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and licensee interview, licensee did not meet the criteria for staffing ratio since licensee was providing care to 8 children under the age of 4 years. This poses an immediate risk to the health and Safety of children in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee agreed to submit a written plan of correction stating how she will ensure that the ratio and capacity are being followed at all times to Licensing for review by 05/20/2022. Licensee will be in advise two parents in care to seek alternate childcare in order to be in compliance.
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:Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2022 12:17 PM - It Cannot Be Edited


Created By: Betzayra Cervantes On 05/19/2022 at 11:29 AM
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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 566216070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and licensee interview, the licensee did not have proof of purchase or service tag for the fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit proof purchase or service for the fire extinguisher to LPA Cervantes via email, fax, or by mail by 06/02/2022.
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 LPA record review and licensee interview, the licensee did not complete Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit proof of Mandated Reported Training to LPA Cervantes via email, fax, or by mail by 06/02/2022.
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:Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/19/2022 12:17 PM - It Cannot Be Edited


Created By: Betzayra Cervantes On 05/19/2022 at 11:29 AM
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: BERNAL FAMILY CHILD CARE
FACILITY NUMBER: 566216070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and licensee interview, the licensee did not renew Pediatric First Aid/CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will submit proof of Pediatric First Aid/CPR certification to LPA Cervantes via email, fax, or by mail by 06/02/2022.
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:Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


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