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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274414151
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:51:21 AM


Document Has Been Signed on 02/09/2023 11:51 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:DOMINGUEZ, MARIA ELENAFACILITY NUMBER:
274414151
ADMINISTRATOR:DOMINGUEZ, MARIA ELENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 229-9918
CITY:KING CITYSTATE: CAZIP CODE:
93930
CAPACITY:14CENSUS: 3DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Maria Elena DominguezTIME COMPLETED:
12:10 PM
NARRATIVE
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On 02/09/2023 at 10:10 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Maria Elena Dominguez, for an annual inspection and explained the reason for the visit to them. Present during today's visit was licensee with 3 children: two infants and one preschool. Adults living in the home are licensee and their spouse. Days and hours of operation are Monday through Friday 5:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 02/08/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA inspected inside and outside of the home. LPA observed no fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have a dog and it's vaccinated. LPA observed a 3A40BC fire extinguisher that was serviced on 06/06/22. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the top kitchen cabinet and the top shelf of the laundry closet. Backyard is fenced. Off limit areas: three bedrooms, one bathroom, garage, 2 sheds, right and left side yards.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license with an assistant. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.


Continues on report dated 02/09/2022 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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 5


Document Has Been Signed on 02/09/2023 11:51 AM - 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: DOMINGUEZ, MARIA ELENA
FACILITY NUMBER: 274414151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023

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 record review, the licensee did not comply with the section cited above in which licensee's mandated report training was last atken on 11/18/2019 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee will take the mandated reporter training for child care providers at WWW.MANDATEDREPORTERCA.COM and will submit the certificate of completion to the San Jose Regional Office (SJRO) by close of business on February 23, 2023.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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 which Child 04 is missing LIC 9224 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee will provide LIC 9224 to parents to complete and licensee will submit a copy of the completed form to SJRO by close of business on February 23, 2023.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/09/2023 11:51 AM - 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: DOMINGUEZ, MARIA ELENA
FACILITY NUMBER: 274414151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in which Child 01 and 04 are missing 15 minute sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee will check and document each infants sleep every 15 minutes and will submit a sleep log for each infant with two or three days worth of documentation to SJRO by close of business on February 23, 2023.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, MARIA ELENA
FACILITY NUMBER: 274414151
VISIT DATE: 02/09/2023
NARRATIVE
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Continuation of report dated 02/09/2022 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 08/20/22. LPA reviewed 10 children’s files and observed Child 01 and 04 are missing 15 minute sleep logs and child 04 is missing LIC 9224. LPA observed that the Licensee has expired Mandated Reporter training, training was completed on 11/18/19. Licensee has Pediatric CPR/1st Aid expiring 04/13/24. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with licensee and 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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed in Spanish with the licensee, Maria Elena Dominguez. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5