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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243809958
Report Date: 09/05/2019
Date Signed: 09/05/2019 11:38:22 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:GOMEZ, BERTHA FCCFACILITY NUMBER:
243809958
ADMINISTRATOR:GOMEZ, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 382-2612
CITY:PLANADASTATE: CAZIP CODE:
95365
CAPACITY:14CENSUS: 4DATE:
09/05/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bertha Gomez - LicenseeTIME COMPLETED:
11:30 AM
NARRATIVE
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(2) On 9/5/2019 at 9:00am Licensing Program Analysts (LPAs), Joseph Pacheco and Jose Penate, conducted an unannounced Annual/Random inspection today. LPAs met with Spanish speaking Licensee, Bertha Gomez, toured the home, and census was taken. Staff and Children were spoken to during visit. There are no "bodies of water" or firearms in this home. Poisons are inaccessible to children. Cleaning supplies were observed in an unlocked cabinet underneath the bathroom sink. LPAs observed medicated ointment in an accessible drawer in the kitchen. There is no fireplace. There is a working fire extinguisher, smoke and carbon monoxide detector, and there is adequate heating and ventilation for safety and comfort. There are no stairs in the home. There is a working telephone. Adequate supervision is being provided during this visit. Children are supervised when outside in the front yard and backyard play area. The front yard of the home is gated. Licensee has no pets at this home. Capacity as specified on the license is being maintained. Staff-child ratios are maintained. Licensee did not have a current roster of the children. Fire drills are conducted and documented with the date and time every six months. The most recent fire drill was conducted on 4/15/2019. 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. Pediatric CPR/First Aid are current and expire on 12/31/2019. AB 1207 Mandated Reporter certification is current and expires on 2/24/2021.

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



CONTINUED ON 809-C
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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 3
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: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2019
Section Cited

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Operation of a family child care home. 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. This requirement was not met as evidenced by:
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LPAs observation of cleaning compounds in an accessible cabinet underneath the bathroom sink. LPAs also observed medicated ointment in an accessible drawer in the kitchen. These items pose a potential risk to the health, safety, or personal rights of children in care.
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Type B
09/09/2019
Section Cited

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Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement was not met as evidenced by: LPAs observation that Licensee did not have a current LIC 9040 Children’s Roster on file.
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This item poses a potential risk to the health, safety, or Personal rights of children in care.
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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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958
VISIT DATE: 09/05/2019
NARRATIVE
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An exit interview was conducted with Licensee. LPA provided Licensee with information regarding providing incidental medical services to children, the CDSS Provider Information Notices (PINs) communication system, and some important resources and information links offered on the CDSS website. Lead safety information was provided in accordance with AB 2370, Chapter 676, Statues of 2018.

Hours of operation are Monday through Friday from 6:00am – 5:30pm or as arranged.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found
(see LIC809-D):

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3