197493840-4-23-2025-58-CC-LHEZ-DFTU3E-20250417151324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197493840
Report Date: 04/17/2025
Date Signed: 04/23/2025 09:59:27 AM

Document Has Been Signed on 04/23/2025 09:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	GOMES FAMILY CHILD CARE		FACILITY NUMBER:	197493840
ADMINISTRATOR/ DIRECTOR:	GOMES, MARIANE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 399-1720
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 5	DATE:	04/17/2025
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Mariane Gomes, Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:25 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 Analyst (LPA) Lilia Hernandez conducted an unannounced annual required inspection to the above facility on 04/17/2025. LPAs arrived at the facility at 11:45AM, identified self and met with Mariane Gomes, Licensee, who guided analyst on a tour of the facility. Licensee was provided a copy of the LIC 126 Entrance Checklist to help facilitate the inspection. LPA observed 1 infant, 3 preschool and 1 school age children in care. Licensee’s spouse was also present. Capacity as specified on the license is being maintained. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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. Facility operation hours are Monday to Saturday from 7:00AM to 6:00PM. An updated LIC279 was provided to the LPA to reflect updated days and hours of operation. The family child care home is a 4 bedroom, 2 bathroom, living room, dining room, and kitchen. Current facility sketch reviewed, and Licensee confirmed that 1 bedroom, 1 bathroom, and dining room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by the use of a safety gate, and doors remain closed and locked. ---Page 1 of 4

Rita Ramos	TELEPHONE: (424) 301-3061
Lilia Hernandez	TELEPHONE: 424-301-3071
	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMES FAMILY CHILD CARE	FACILITY NUMBER: 197493840
	VISIT DATE: 04/17/2025

NARRATIVE

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Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. Per Licensee, detergents, cleaning compounds, medication and other hazardous items inaccessible to children are kept in a locked cabinet above the refrigerator. LPA did not observe any detergents, cleaning compounds, medication and other hazardous items accessible to children during the inspection.

Per Licensee, there are no firearms on the premises. Licensee was advised that storage of firearms and other dangerous weapons shall be locked, ammunition shall be stored and locked separately from firearms, and any firearms or weapons in the home shall be reported to the Department.

There is a working fire extinguisher that was purchased on 11/05/2024. LPA observed a smoke detector and carbon monoxide detector in the home that were tested and operable. LPA also observed adequate heating and ventilation for safety and comfort.

There is currently 1 infant’s in care.
LPA discussed the safe sleep regulations with licensee discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Licensee disclosed that infant equipment is replaced yearly.

Licensee was reminded that children in care are to be supervised at all times and made aware that 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 area accessible to children is the backyard. All other outdoor areas are inaccessible by a gate with a lock. LPAs observed no swimming pool or other bodies of water on the premises.
---Page 2 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMES FAMILY CHILD CARE	FACILITY NUMBER: 197493840
	VISIT DATE: 04/17/2025

NARRATIVE

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LPA reviewed a sample of children’s files and observed files were complete with LI700 Identification and Emergency information, LIC627 Consent for Emergency Medical Treatment, and LIC995 Notification of Parents Rights. Licensee has a current roster of the children. An emergency fire/disaster drill was completed within the last 6 months. Last documented fire/disaster drill was on 10/28/2024. Licensee’s Mandated Reporter Training was completed on 11/06/2024. Licensee’s pediatric CPR/First Aid expires on 10/2025.

Licensee and spouse records were reviewed for approved Pediatric First Aid and CPR certification, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

When a child shows signs of illness, the child shall be separated from other children and the nature of the illness determined. If it is a communicable disease, the child shall be separated from other children until the infectious stage is over. Per Licensee, children who show signs of illness are kept separate from other children in the room where children sleep until parents pick up the child.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
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SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMES FAMILY CHILD CARE	FACILITY NUMBER: 197493840
	VISIT DATE: 04/17/2025

NARRATIVE

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There were no deficiencies cited during today’s visit.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The Notice of Site Visit must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview conducted and report was reviewed with Mariane Gomes, Licensee.

---Page 4 of 4

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia Hernandez	TELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

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