163901684-9-18-2019-04-CC-ROCA-BG5PZ2-20190918114449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 163901684
Report Date: 09/18/2019
Date Signed: 09/18/2019 11:45:09 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:	MOMBERGER, DAWN FAMILY CHILD CARE		FACILITY NUMBER:	163901684
ADMINISTRATOR:	MOMBERGER, DAWN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 925-1680
CITY:	LEMOORE	STATE: CA	ZIP CODE:	93245
CAPACITY:	14	CENSUS: 7	DATE:	09/18/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Dawn Momberger		TIME COMPLETED:	12:00 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	Licensing Program Analysts (LPA’s) Ruby Ocegueda and Rene Mancinas Jr. conducted an unannounced annual/random inspection. LPA met with Licensee Dawn Momberger who provided a tour of the home, inside and outside, as shown on the facility sketch. There is an in-ground swimming pool in the back yard. Swimming pool fence meets fencing requirements per regulation. There are no firearms or ammunition in the home. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children. There is no fireplace. The fire extinguishers, smoke detectors, and carbon monoxide indicator meet Community Care Licensing (CCL) regulations. There are no stairs in the home. Safe toys and play equipment are observed. There are three dogs in the home that are kept in inaccessible rooms. Licensee understands the liability of pets around day-care children and accepts three responsibility of any action taken by pets. Licensee has a working telephone and the above telephone number was verified. Adequate supervision is being provided during this inspection. The backyard is inaccessible to children in care. Daycare children have access to front unfenced area, licensee understands she must have 100 percent supervision during outside play. Capacity as specified on the license is being maintained. Staff-child ratios are maintained. Children’s records contain all emergency information specified by regulation. Required immunization (Pertussis/Measles/Influenza) were verified and written declaration declining flu shot was verified. LPA discussed required Mandated Reporter Training to be completed by 10/18/19 herself and assistant. There are no excluded individuals present at this home. All adults who reside or work in the home have a criminal record clearance or exemption as indicated on LIS 531 – Facility Personnel Report Summary. The Licensee and other personnel as specified have completed training on preventative health practices including pediatric CPR and first aid; Expires: 7/15/20. Report continued a 809-C

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019

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: MOMBERGER, DAWN FAMILY CHILD CARE	FACILITY NUMBER: 163901684
	VISIT DATE: 09/18/2019

NARRATIVE

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

LPA provided Licensee with information regarding the California Department of Social Services (CDSS) Provider Information Notices (PINs) communication system; information regarding Safe Sleep Regulations; AB 2370, Chapter 676, Statutes of 2018, requiring child care providers to inform parents and/or guardians with lead safety information, and other important resources and information links offered on the CDSS website.

Business hours are Monday through Friday 7:00 AM to 7:00 PM and other hours as arranged.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations no deficiencies are observed today.

A COPY OF THIS REPORT MUST REMAIN IN THE FACILITY FOR PUBLIC REVIEW

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Ruby Ocegueda	TELEPHONE: (559) 341-5808
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019

LIC809 (FAS) - (06/04)

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