Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426211932
Report Date: 12/02/2015
Date Signed 12/02/2015 12:20:11 PM

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:
426211932
ADMINISTRATOR:TOMASA BERNALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 562-8124
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:14CENSUS: 4DATE:
12/02/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tomasa BernalTIME COMPLETED:
12:30 PM
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(3) Licensing Program Analyst (LPA) Maria Mueller conducted an annual random visit and met with licensee, Tomasa Bernal. LPA observed 4 children eating lunch in the dining table. The day care is conducted in the living room and one additional bedroom. LPA observed age appropriate toys, games, books, plastic play kitchen, tables and chairs. One bedroom is used for napping, LPA observed age appropriate cribs.
The bathroom is clean and free of toxins. The kitchen is accessible to children, and the cabinets are secured with tot locks. The outdoor play area is completely fenced, LPA observed age appropriate toys, play structure, shade area, and bike area.

The fire extinguisher was services March 16, 2015. The safety drills were conducted and documented, last drill was conducted November 2, 2015. The smoke alarm was tested and was found operational. Carbon monoxide was tested and was found operational. Licensee is current with CPR and First Aid which expires August 2, 2016.

Child's file reviewed.

Licensee stated that there are no guns or ammunition in the home. Licensee does not provide Incidental Medical Services. Licensee was given a packet of information regarding Incidental Medical Services.

Today, no deficiencies cited under Title 22 Division 12.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Maria MuellerTELEPHONE: (805) 729-8797
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2015
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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