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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103901414
Report Date: 01/03/2023
Date Signed: 01/03/2023 04:56:30 PM


Document Has Been Signed on 01/03/2023 04:56 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, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:GOMEZ,CONCEPCIFACILITY NUMBER:
103901414
ADMINISTRATOR:GOMEZ,CONCEPCIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 225-4803
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:14CENSUS: 5DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:GOMEZ, CONCEPCIONTIME COMPLETED:
05:15 PM
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On 1/03/2023 Licensing Program Analyst (LPA), Stephanie Vega-Gonzalez, conducted an unannounced Annual Required Inspection and was met by Licensee, Concepcion Gomez. LPA explained the reason for the visit. Also present was Assistant #1, Adult #1, and Assitant #2.. Licensee is Spanish Speaking and LPA assisted with interpretation. Days and hours of operation are Monday through Friday 6:00am – 6:00pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that converted garage “Day Care Room”, Kitchen, Living Room, and part of backyard are used for children in care and are accessible. Upon today's inspection Back Yard is placed on "OFF-LIMITS" until inspection of pool gate is completed by Community Care Licensing (CCL). All other rooms are off-limits and made inaccessible by use of doorknob spinners. Swimming pool is fenced per regulation. LPA observed that the pool gate is not self-latching, self-closing. LPA observed that pool fence does open away from the swimming pool. Per 1/29/2009 Annual Inspection, licensee was previously issued a waiver for the bedroom windows by Fresno County. The information regarding a waiver revealed that the two bedroom windows, Bedroom 3 and Bedroom 4, open directly to the pool and window alarms were installed. LPA observed that window alarms were functioning, yet Licensee stated that the new window alarms had arrived on today’s date. LPA observed Licensee install new window alarms and Licensee tested window alarm. LPA observed that window alarm was strong. LPA observed that Bedroom 3 and Bedroom 4 were inaccessible by doorknob spinners. During record review Licensee was not able to provide the 1/29/2009 wavier to LPA. There are no firearms or ammunition on the premises.

LPA observed all poisons are kept in a locked storage area in backyard shed that is locked. LPA observed that detergents and cleaning compounds are located under kitchen sink that has a child proof lock. LPA observed clothing detergents in closet in Day Care room that are placed out of reach and inaccessible to children.

(Continue on LIC809-C)

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
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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Document Has Been Signed on 01/03/2023 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: GOMEZ,CONCEPCI
FACILITY NUMBER: 103901414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102417(g)(5)(A)
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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.

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 that, LPA observed that pool gate did not self close or self latch when opened. LPA observed that Licensee had a black key lock on gate and that key was indoors when asked to open pool gate. Licensee was not able to provide LPA with a copy of their pool waiver, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2023
Plan of Correction
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Licensee stated they will fix pool gate by adding a self latching lock and ensure that gate closes on it's on. Licensee understands that backyard will be off-limits until self latching and self closing gate had been inspected by CCL. Licensee stated they will watch video on "Bodies of Water Requirements in Child Care" and write a statement and submitted it to CCL by POC due date. www.ccld.childcarevideos.org

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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2023 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: GOMEZ,CONCEPCI
FACILITY NUMBER: 103901414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 that, LPA observed that Assistant #1 did not have proof of their TDAP in facility file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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Licensee will provide proof of Asssitant #1's TDAP immunization to CCL by POC due date.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 that Child #1 and Child #2 did not have LIC 627, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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Licensee stated that they will provide proof of Child #1 and Child #2 LIC 627 to CCL by POC due date.
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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ,CONCEPCI
FACILITY NUMBER: 103901414
VISIT DATE: 01/03/2023
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LPA observed that medication and other hazardous items are made inaccessible and located in cabinet above microwave in kitchen. LPA observed a large dog in facility. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets.

The fireplace located in the Living Room and is made inaccessible by a large coffee table placed in front of fireplace. LPA observed that fireplace does have a metal screen that does not have a lock. Licensee stated that fireplace will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. LPA observed licensee test the smoke detector and carbon monoxide. Licensee understands to test both smoke detector and carbon monoxide periodically for functionality. LPA did not observe any stairs in this home. The home has working telephone service and LPA confirmed the phone number is (559) 225-4803.

LPA observed infants in care. LPA observed one two play yard for each infant in care, and that play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. License stated that infants are not swaddled while in care. Licensee physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s Mandated Reporter Training was completed on 8/22/2022. Assistant #1’s Mandated Reporter Training was completed on 10/21/2022. Licensee’s pediatric CPR/First Aid expires on 2/27/2023. Assistant #1’s pediatric CPR/First Aid expires on 10/29/2024. A review of records indicates that Licensee had immunization records on file for influenza, pertussis and measles. A review of records indicates that Assistant #1 had immunization records on file for influenza and measles.

(Continue on LIC809-C)

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ,CONCEPCI
FACILITY NUMBER: 103901414
VISIT DATE: 01/03/2023
NARRATIVE
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All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) re not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



Licensee Concepcion Gomez 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, 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 and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

LPA discussed the safe sleep regulations with Licensee Concepcion Gomez 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 infants devices with the CPSC to be notified of any recalls on their purchased equipment.

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/process



(Continue on LIC809-C)
SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ,CONCEPCI
FACILITY NUMBER: 103901414
VISIT DATE: 01/03/2023
NARRATIVE
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Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Concepcion Gomez

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Stephanie Vega-GonzalezTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8