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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103911016
Report Date: 12/18/2019
Date Signed: 12/18/2019 11:44:27 AM

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, MA DEL FAMILY CHILD CAREFACILITY NUMBER:
103911016
ADMINISTRATOR:GOMEZ, MA DELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 289-3865
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:14CENSUS: 11DATE:
12/18/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ma Del GomezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ginny Badhesha made a Case Management 90 day inspection. LPA toured the facility both inside and outside as shown on the facility sketches (LIC 999A), and a census taken. LPA explained that the purpose of today's visit was to conduct a 90 day follow-up. Present in the home was the Licensee, Licensee's assistant (Blanca Estrada) and 11 day care children. Fireplace is screened and inaccessible to children in care. Stairs are barricaded when children under age 5 years old are present. LPA observed plenty of age appropriate toys in the day-care room and observed that the house was clean and free of toxins. The knives and medications are stored up high in a cabinet. The chemicals and cleaning supplies are stored in the garage which is always kept locked. The backyard has a fence that goes all around. There was plenty of shade. Children's files were reviewed along with the children's roster and everything was completed and up to date. LPA spoke about the safe sleep regulations with Licensee and reminded her to not store anything inside the cribs and playpens. LPA also provided licensee with a safe sleep brochure and the new lead brochure. Licensee has a working fire extinguisher, carbon monoxide and smoke detector. There was adequate heating and ventilation for safety and comfort. Licensee stated that she does not have any guns or ammunition in the home and LPA did not observe any bodies of water during the inspection. There is a working telephone and number was verified. Capacity as specified on the license is being maintained.

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.

Days and hours of operation are Monday through Friday; 5:00am-10:00pm.

(Continued on 809-C)
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Gagandip BadheshaTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: GOMEZ, MA DEL FAMILY CHILD CARE
FACILITY NUMBER: 103911016
VISIT DATE: 12/18/2019
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Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies were cited today.

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

A Notice of Site Visit Form (LIC 9213) was posted on parent's board and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Gagandip BadheshaTELEPHONE: (559) 575-6900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
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