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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493632
Report Date: 07/14/2022
Date Signed: 07/14/2022 01:04:16 PM

Document Has Been Signed on 07/14/2022 01:04 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
197493632
ADMINISTRATOR:GOMEZ, ESTELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 808-9569
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estela Gomez/LicenseeTIME COMPLETED:
01:15 PM
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On 07/14/22 Licensing Program Analyst (LPA) Silva Garibyan conducted an unannounced Annual Required Inspection and was met by Licensee, Estela Gomez. Also present was licensee’s husband. Days and hours of operation are Monday – Friday from 7:30 a.m. to 6:00 p.m..

LPA toured the home inside and outside and a census was taken. There were five children present (including two infants). Current facility sketch was reviewed. The home is a one story single family house that includes:



· 3 bedrooms; bedroom #1 is on limits, bedroom #2 and #3 are off limits. Please note, bedroom #3 is the master bedroom and includes an en suite bathroom (off limits) and access to the attic (off limits).
· 1 family room off the front entrance of the facility which is on limits. According to the licensee, this is where primary care will be provided.
· 1 dining-room/living-room combination area that includes a fireplace (on limits).
· 1 kitchen (on limits).
· 1 laundry room off the kitchen area (off limits).
· 1 main hallway where all the bedrooms are and where the children's bathroom is located (on limits).
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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493632
VISIT DATE: 07/14/2022
NARRATIVE
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· 1 front-yard (off limits).
· 1 backyard area that includes a pool area (on limits).
· 2 bathrooms; 1 bathroom is in the main hallway area (on limits) and 1 in the master bedroom (off limits).
The attached side house that includes a separate entrance and 1 living-room, 1 kitchen, 1 bedroom, 1 bathroom, 1 digitally locked closet, and sliding glass doors from the bedroom that lead into the backyard area. According to the licensee, this attached side house is completely off limits. According to the licensee, she plans to move her day care to the attached side house. Licensee will provide an updated Facility Sketch to the analyst assigned. Per the licensee, the residents at the facility are the licensee, her husband, her daughter, and her three minor grandchildren.
There is a pool in the backyard. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the dining/living room is made inaccessible by a screen and 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. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 436--2446.

There are currently two infants in care. LPA discussed Safe Sleep Regulations with licensee.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493632
VISIT DATE: 07/14/2022
NARRATIVE
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 There is one crib or play yard for each infant in care, cribs and 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. Infants are not swaddled while in care. Provider 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.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee does not currently have an infant sleep log in infant’s files. Licensee has not completed the Mandated Reporter Training.. Licensee’s pediatric CPR/First Aid expired on 11/17/21. Licensee’s and husband’s immunization records were not available for review.

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.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493632
VISIT DATE: 07/14/2022
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Incidental Medical Services (IMS) are / 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. 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.

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.

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.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 01:04 PM - It Cannot Be Edited


Created By: Silva Garibyan On 07/14/2022 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the licensee does not have a current Mandated Reporter Training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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LIcensee will complete Mandated Reporter training and email the verification certificate of completion on or before the end of business day on 7/21/2022. LPA provided the trainining website address. www.mandatedreportercom.ca
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 Licensee does not have current Immunization's (influenza, pertussis, and measles) availabel for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensees will email a copy of Licensee's immunizations records by 07/21/2022.
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:Karren Starks
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 01:04 PM - It Cannot Be Edited


Created By: Silva Garibyan On 07/14/2022 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with licensee and record review, the licensee did not comply with the section cited above in CPR/First Aid expired 11/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee will sign up for CPR/First aid and email verication of enrollment to LPA Garibyan via email by end of business day on or before 7/15/2022. Once course is completed licensee will email LPA Garibyan the CPR/First Aid Card.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in the infants files did not have an infant sleep log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee does not currently have an infant sleep log but does conduct physical 15 minute checks for infants 24 months and under. LPA provided licensee with the Infant Sleep Regulation Information as well as an infant sleep log sample. Licensee immediately created the infant sleep log for the current infant in care to begin the log for the 15 minute checks. Provider will provide sleep log documentation via email for 2 days.
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:Karren Starks
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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