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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243809958
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:16:05 PM


Document Has Been Signed on 09/13/2022 02:16 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
FRESNO-CC, 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: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bertha Gomez TIME COMPLETED:
02:25 PM
NARRATIVE
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On 09/13/22 Licensing Program Analyst (LPA), Araceli Gibson conducted an unannounced Annual Required Inspection and was met by Licensee, Bertha Gomez. Days and hours of operation are Monday through Friday 6:00 AM to 4:30 PM.

LPA toured the home inside and outside. Licensee had 6 children in care. Licensee confirmed that the entire home was open for inspection per facility sketch 3 bathroom, 2 kitchens, living room, daycare room, and a room addition accessible to daycare children. LPA Gibson compared facility sketch and observed an addition to the already added room there was a discrepancy. Licensee stated the room was not permitted nor did she notify licensing of this area used as an additional exit leading to the a path outdoors completely fenced in. LPA observed bikes and toys in this area. LPA cited a Type A deficiency and provided LIC999A facility sketch and request for a fire inspection for her large licensed facility. Licensee agreed to immediately cease use of this room. Backyard was further inspected in safe condition and is used for providing care accessible to children. There is no swimming pool or other bodies of water on the premises. 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.

There is no fireplace or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Licensee also stated Planada does not require a pull down fire latch for large day care none was observed by LPA Gibson on the day of the inspection. There is a set of stairs with 3 steps in this home in the non permitted area behind a sliding glass door which is made inaccessible by keeping it locked until inspected by licensing. Safe toys and play equipment are observed. The home has working telephone service and LPAs confirmed the phone number is (209) 882-2612.

Continue 809C, 809D

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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Document Has Been Signed on 09/13/2022 02:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above Licensee permitted a family member to run an eyelash business during daycare hours and allowed entrance of the customer throught the licensed daycare room with children photo was taken, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee and family member agree and understand the lash business may be conducted only while daycare children are not present. Customer left prior to LPA Gibson leaving the facility.
Type A
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review facility sketch, the licensee did not comply with the section cited above Licensee added an additional room to a room that was already a room addition. Licensee stated the room in between connecting the bedroom is not permitted, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee agrees to cease use of the nonpermitted room immediately until it can be properly inspected. Licensee agrees to submit a new faciltiy sketch Lic999A and new fire inspection request LIC 9054. Licensee agrees to compling with regulations as required for her large license.

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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 02:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 did not have current documentation for Child # 3 infant on sleep log for labored breathing, tempature or signs of distress. Licensee stopped documentation in April of 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee agrees to begin documentation every 15 minutes checks on Child # 3 infant on a sleep log for labored breathing, tempature or signs of distress.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958
VISIT DATE: 09/13/2022
NARRATIVE
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There is currently 1 infant enrolled. LPA discussed Safe Sleep Regulations with licensee. 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. Licensee admitted to not documenting any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing since April of 2022 LPA issued citation Type B. 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’s Mandated Reporter Training was completed on 08/21/2021. Licensee’s pediatric CPR/First Aid expires on 12/18/2023. Licensee has documentation on file all immunization records on file for influenza, pertussis and MMR.

All adults who reside or work in the home have a criminal record clearance or exemption, LPA issued Type A and civil penalty as it was observed Licensee permitted a family member to conduct an eyelash business during daycare business hours and allow entrance to a customer through daycare room. Customer is an uncleared adult present at this home. See 809D for further.

Incidental Medical Services (IMS) 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.



Continue 809 C, 809D
SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ, BERTHA FCC
FACILITY NUMBER: 243809958
VISIT DATE: 09/13/2022
NARRATIVE
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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.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, Civil Penalty and 809 D) Licensee was provided a copy of appeal rights.

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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