015700206-12-30-2020-52-CC-RRED-BWSU7M-20201230142009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700206
Report Date: 12/30/2020
Date Signed: 12/30/2020 02:21:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	GOMEZ VARGAS, IVON		FACILITY NUMBER:	015700206
ADMINISTRATOR:	GOMEZ VARGAS, IVON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 724-0693
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	14	CENSUS:	DATE:	12/30/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Ivon Gomez Vargas		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Due to the COVID-19 Pandemic, this pre-licensing inspection was conducted via tele-visit through Face Time. Licensing Program Analyst (LPA) Renee Reed, met with Ivon Gomez-Vargas on 12/30/2020 at approximately 10:48 am for an ANNOUNCED PRELICENSING INSPECTION via FaceTime. Present during the inspection were applicant and fingerprint cleared husband Camilo Perez Saabi. LPA and applicant toured the home to conduct a Health and Safety Inspection. The facility plans to operate 8::30 AM to 5:30 PM, Monday through Friday. Per Applicant will provide occasional after hours care. Description of Home: The residence is a single story which consist of 4 bedroom, 2 bathroom, living room, dining room/kitchen combination backyard and garage. The home has central heat and air. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS are 3 of the bedrooms, one located to the left side of the hallway towards the back of the home, the other two located on the right side and bathroom at end of hallway, kitchen, closets, garage and left side of backyard which will be inaccessible by closed and/or locked doors and visual supervision. The ON LIMIT AREAS are dining room, family room to the right, first bedroom and bathroom to the left of the home, as well as part of the backyard. The ISOLATION AREA: Area in the on limits bedroom. There are ample age appropriate toys, learning materials, and equipment that are safe and in good condition All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. See 809-C

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ VARGAS, IVON	FACILITY NUMBER: 015700206
	VISIT DATE: 12/30/2020

NARRATIVE

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There is a fireplace in the family room which is covered by a book shelf to prevent access by children in care. There are multiple working smoke detectors and carbon monoxide detectors present. The facility has a fully charged 2A10BC fire extinguisher, a pull down fire alarm. working telephone, and fully stocked First Aid Kit. A Fire Clearance was granted on 12/21/2020 by the Dublin Fire Prevention Services noting (GARAGE IS OFF LIMITS TO CHILDREN).There are age appropriate furnishings, toys and equipment in the day care room. The bedroom has a changing table, mats and cots for children's sleeping. The bathroom has a working toilet and faucet in new condition. Per applicant, there are no firearms located or stored on the premises. The home has a fully fenced back yard area. The backyard has a deck with one step down entering the grass area, a covered sandbox with no sand at the time, a gardening area to the right and a basketball court to the left. There are no pools, hot tubs or other accessible bodies of water. There are 3 locked gates in the backyard and 2 locked sheds on the left side of backyard,

The applicant’s Health and Safety training is completed and CPR and First Aid certificate is current and expires on 08/30/2022. Mandated Reporter Training is current and expires 11/23/2022. The applicant is in compliance with the immunization law which pertains to day care providers. All electrical outlets are safety outlets. Proof of control of Property was reviewed. A packet of forms pertaining to the children’s files and facility files were reviewed and discussed.

Individual Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Home 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.

Applicant is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Applicant was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov.
See 809-C

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ VARGAS, IVON	FACILITY NUMBER: 015700206
	VISIT DATE: 12/30/2020

NARRATIVE

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LPA reminded the applicant of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. LPA discussed Unusual Incidents Reports.

The applicant is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

LPA Reed provided a copy of Safe Sleep-in Child-Care brochure, a handout "What Does A Safe Sleep Environment Look Like?" and a copy of the new California Car Seat Law Changes.

LPA discussed and reviewed Covid-19 self assessment, postings, guidance and links.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

This home is recommended for licensing on 12/30/2020. This report shall remain on file for 3 years. Exit interview conducted with applicant.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Renee Reed	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC809 (FAS) - (06/04)

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