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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610558
Report Date: 08/12/2021
Date Signed: 08/12/2021 01:51:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:DOMINGUEZ, ANA MARIA FAMILY CHILD CAREFACILITY NUMBER:
136610558
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Ana Maria Dominguez, ApplicantTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Diana Sanchez conducted a Prelicensing inspection to the facility today. LPA met with Applicant Ana Maria Dominguez. The two story three bedroom home was toured and inspected to ensure an environment safe for the care and supervision of children. The fire extinguisher, carbon monoxide and smoke detector meet requirements and are operational. All hazardous items were latched/locked and not accessible to children.
Daycare areas includes: Living room, dining room, hallway bathroom and backyard. Off limits areas includes: all areas in the second floor where the bedrooms are located and garage.

The kitchen has been properly barricaded with a baby gate. The facility has a fenced back yard that is clean and has several toys.

A review of all adults living in this home who require caregiver background checks have received criminal record and child abuse clearances or exemptions. First Aid and CPR are up to date. Applicant stated that they do not have hand gun or ammunition in this house.

Applicant stated that she will have the children take naps in the living room area. LPA observed sleeping pads that would be used for napping. The applicant has sufficient toys and equipment available.

LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA provided applicant with the SIDS safe sleep printout and advised her of the importance of child abuse reporting, children’s records, immunization, shaken baby syndrome, and the YMCA Resource Center. LPA explained clearance requirements for persons over 18 residing or working in the facility. Applicant understood that physical discipline/corporal punishment and smoking shall never be permitted in the child care program. Applicant was also advised that exersaucers, bouncy, rockers, walkers shall never be permitted in the child care program.
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Diana SanchezTELEPHONE: (619) 767- 2210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOMINGUEZ, ANA MARIA FAMILY CHILD CARE
FACILITY NUMBER: 136610558
VISIT DATE: 08/12/2021
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The maximum number of children for whom care shall be provided when there is an assistant provider in the home, including children under age 10 who live in the licensee's home and the assistant provider's children under age 10, shall be either: Twelve (12) children with no more than four of whom may be infants or Fourteen (14) children, at least two of the children are at least six years of age and no more than three infants with landlord consent.
Facility is currently in substantial compliance; all requirements for a large license have been met. A large license for a maximum capacity of 14 children will be granted effective today 08/12/2021.

Community Care Licensing WEB SITE: http://www.ccld.ca.gov

Licensee is Spanish speaking and requested report to be translated. LPA translated report and licensee stated she understood.

An exit interviewed was conducted with applicant Ana Maria Dominguez and a copy of this report left at the facility.

SUPERVISOR'S NAME: Jason GarayTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Diana SanchezTELEPHONE: (619) 767- 2210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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