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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700448
Report Date: 10/30/2020
Date Signed: 11/04/2020 04:56:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GOMEZ-CASTILLEJOS FAMILY CHILD CAREFACILITY NUMBER:
197700448
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
10/30/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Monica Gomes-CastillejosTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) King-Lewis conducted a COVID-19 Emergency Response Tele-Visit Prelicensing Relocation Inspection with Applicant Monica Gones-Castillejos, who guided analyst on a tour of the facility. This is a single story 3 bedroom, 2 bathroom home with living room, kitchen, family room, dining room, laundry room, attached garage and rear yard. LPA did not observe any pool/spa on the premises. The applicant is the only person residing in the home. Days/hours of operation will be 7 days a week, Sunday through Saturday less than 24 hours.

Incidental Medical Services (IMS) policy was discussed, informing applicant when any IMS is provided, a plan for providing IMS must be submitted to the Department prior to providing care to a child that need IMS. The plan shall state the type of IMS the facility will be offering, stating the person providing care has been trained to provide the named IMS. The plan will also provide the steps that will be taken when IMS is provided to a child.

LPA also reviewed COVID -19 procedure and best practices.

The following information regarding ADA was discuss and the following information 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

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ-CASTILLEJOS FAMILY CHILD CARE
FACILITY NUMBER: 197700448
VISIT DATE: 10/30/2020
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Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation. Report to the following email: unusualincidentreport@dss.ca.gov

Applicant was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B). Email all Unusual Incident/Injury

Applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Physical Plant: LPA observed the home to be clean and orderly, fireplace screened shall be secure to not fall or tip over, age appropriate toys and play equipment per licensee are sturdy and secure into the ground, LPA observed working smoke detector and carbon monoxide detector. Applicant inform smoking is prohibited, applicant stated no one smokes in the home, LPA discuss Health Section 1596.846(b) and (c)–102417 (g)(10) and provided applicant with a visual copy of prohibited items. LPA did not observe prohibited items during the inspection. There is a designated area for ill child(ren) as necessary, applicant stated no weapon/firearms in home, facility sketch complete, the off limit area are the master bedroom and bathroom, bedroom #3, living room, Laundry room, and attached garage. Applicant has a work phone that will be available and charge during daycare hours, LPA observe a fully charge 2A10BC fire extinguisher during the inspection. Applicant made poisons, medication and cleaning items inaccessible to children secured with a kiddy lock. Applicant informed that a higher lever of inaccessible should be taken as children discover how to open cabinets secure with a kiddy lock.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ-CASTILLEJOS FAMILY CHILD CARE
FACILITY NUMBER: 197700448
VISIT DATE: 10/30/2020
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Kitchen: The following are inaccessible: Sharp items, lighter, and cleaning items. LPA observed the refrigerator and freezer to be clean. LPA discuss with applicant food shall be properly stored or refrigerated in container that are labeled with child’s name when supplied by parent. Stove knobs shall be secured with kid safety knobs.

Bathroom accessible to children: The following are inaccessible: shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover. LPA observed a clean, safe and operable Toilet and faucet.

Outdoor: LPA observed the play area to be clear of hazard, no garden tools, poisonous plants, thorn trees cactus, or lawn mower accessible to children. play area is fenced and gated all around, LPA did not observe any body of water on the premises. no pets were observed. LPA did not observe any grill, charcoal or propane tank accessible to children. Play equipment per licensee are sturdy and secure into the ground,



Advisory/Other: LPA observed a first Aid kit with emergency supplies and a thermometer. Applicant’s CPR/First Aid expire 07/13/2021. Preventative Health & Safety completed 07/24/16, Lead training completed 09-24-20. Applicant states all electrical outlets are inaccessible to children. Children will nap on cots.

Documents Provided and or Discussed: The following were provided (via email) to comply with Title 22 requirements: Fire Drill Log, roster, Safe Sleep poster, water lead poster, required postings and list of CCL forms required for child file each child in care. LPA observed the Lead Information Flyer posted. Applicant stated currently does have child care insurance. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

All adults living/residing in the home are fingerprint cleared and associated.
Application Documents: Applicant file is complete with required documentation.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ-CASTILLEJOS FAMILY CHILD CARE
FACILITY NUMBER: 197700448
VISIT DATE: 10/30/2020
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Before licensure the following shall be completed:

Fireplace screened shall be secure to avoid falling or tip over,


Install safety knobs on stove
Tall wall cabinet in day care napping room shall be secure to not fall or tip over
  • The applicant shall make contact with LPA upon correction of the above area in the home.

An exit interview was conducted, and a copy of this report was provided to the applicant on this date.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC809 (FAS) - (06/04)
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