103905608-5-10-2022-04-CC-CHAS-CEAT32-20220510142138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 103905608
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:21:44 PM

Document Has Been Signed on 05/10/2022 02:21 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:	GONZALEZ, BERTHA FAMILY CHILD CARE		FACILITY NUMBER:	103905608
ADMINISTRATOR:	GONZALEZ, BERTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 305-9615
CITY:	SANGER	STATE: CA	ZIP CODE:	93657
CAPACITY:	14	CENSUS: 1	DATE:	05/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bertha Gonzalez		TIME COMPLETED:	03:00 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	On 5/10/22 Licensing Program Analyst, (LPA) Caroline Harris conducted an unannounced annual inspection. LPA met with Licensee, Bertha Gonzalez. Also present was her helper. LPA conducted a tour of the home, inside and outside, as shown on the facility sketches (LIC 999A) provided. The LPA observed all required licensing forms to be posted in a visible location for authorized representatives to view them. A census was taken and there was 1 day care child present. The licensee has one dog that is kept in an area away from the children. The licensee is aware of the safety of children around animals and takes responsibility for any action taken by her pets. The LPA observed inaccessible rooms to be off limits to children by the use of door locks and baby gates. The accessible rooms were the living room, kitchen and dinning area, day care room and hall bathroom. The outdoor play area in the back yard is fenced. Licensee is aware that children are to be supervised when outside an unfenced play area. There are no swimming pools or other bodies of water on the premises. The LPA observed safe toys and play equipment both indoors and outside. There were no poisons observed on the premises accessible to children. Licensee is aware that poisons are required to be locked and inaccessible to children. Cleaning compounds, medications and other hazardous items were inaccessible to children. There are no firearms or ammunition present at this facility. There is no fireplace. There is a working fire extinguisher, smoke detector, carbon monoxide indicator, and adequate heating and ventilation for safety and comfort. The licensee has a complete first aid kit, including bandages, scissor, thermometer, gloves and a first aid manual. There are no stairs in the home. There is a working telephone and the above telephone number was verified. Adequate supervision is being provided during this visit. Capacity as specified on the license is being maintained.

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Caroline Harris	TELEPHONE: (559) 341-4624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GONZALEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 103905608
	VISIT DATE: 05/10/2022

NARRATIVE

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LPA reviewed one child’s files. All required licensing documents were observed in each of the children’s files, including a copy of the Family Child Care Home Notification of Parent's Rights (LIC 995A). Licensee also maintains documentation of immunizations for the children. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. Incidental Medical Services (IMS) are 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.

Fire drills are conducted and documented with the date, time and how many children present, every six months. Licensee is aware that children are never to be left in parked vehicles. 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. 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. Licensee is aware that upon notice from the Department, any excluded individual must be immediately removed from the home and prevented from returning to the home or having contact with children in care. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. Pediatric CPR/First Aid are current and expire on 8/24/23. Licensee also maintains documentation of immunizations against pertussis, measles or influenza for herself and staff. Days and hours of operation are Monday – Friday; 5:30 AM – 5:00 PM.

An exit interview was conducted with the Licensee. LPA reviewed with licensee the Mandated Child Abuse Reporter Training (AB 1207), which the licensee completed on 4/21/22. It is required to be updated every two years. There are currently no infants in care. Information on Lead Poisoning was also provided to the licensee and she was informed that the information is required to be posted on the parent board.

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Caroline Harris	TELEPHONE: (559) 341-4624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GONZALEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 103905608
	VISIT DATE: 05/10/2022

NARRATIVE

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The LPA and licensee discussed the Community Care Licensing website: www.ccld.ca.gov. which provides access to Provider Information Notifications (PINS), Quarterly Updates that inform licensees of new legislation and regulations, trainings, and Licensing forms and updated information. The licensee was also advised that it is her responsibility to stay current with regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited.

An exit interview was conducted and a copy of this report was provided to the licensee, Bertha Gonzalez and was reviewed. This report shall be made available to the public upon request. The LIC 9213 Notice of Site Visit form was provided to the licensee and must remain posted for 30 days.

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.

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Caroline Harris	TELEPHONE: (559) 341-4624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC809 (FAS) - (06/04)

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