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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274414151
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:24:51 PM


Document Has Been Signed on 05/22/2024 01:24 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
SAN JOSE CC RO, 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: 4DATE:
05/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Maria Elena DominguezTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analysts (LPA) Martha Jimenez-Villanueva met with licensee Maria Elena Dominguez on May 22, at 9:32 am for an unannounced annual inspection. LPA explained the nature of today’s inspection. Licensee and assistant Ma Soledad had 4 children in care: one infant and three toddlers. Present (adults) were licensee and her assistant. Days and hours of operation are Monday to Friday from 5:000am to 5:30pm. Adults living in the home are the licensee, licensee's husband. Licensee’s husband arrived at home later during today visit.

A review of staff records on 5/21/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Maria Elena Dominguez 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.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed the home is one story home and LPA observed no stairs at home. A barricaded fireplace, no wall heater and no bodies of water. Licensee states there no weapons at home. LPA observed one dog, licensee states the dog is vaccinated and stay outside of the home in the fenced right side of the yard. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children and stored on the top of a cabinet in the kitchen and in the top shelf t on the laundry room. LPA observed a carbon monoxide detector and a smoke detector operable. LPA observed a full 3A40BC fire extinguisher was serviced on 02/04/2024. The home has fenced backyard. Off limit areas: three bedrooms, one bathroom, garage, 2 sheds, right and left side yards.

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SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, MARIA ELENA
FACILITY NUMBER: 274414151
VISIT DATE: 05/22/2024
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LPA observed licensee CPR and First Aid Certification expiring on 04/13/2024 and licensee's assistant have CPR and First Aid certification expiring on 01/15/2026. LPA observed licensee completed Mandated Reporter training dated 08/11/2023 and licensee’s assistant missing Mandated Reporter Training and LIC 9052 Notice Employee Rights.

LPA took a picture of a current roster of the children and a fire and disaster drill log which was last completed on 03/04/2024. LPA reviewed five children's files and observed all forms are completed and children have current immunization records with exemption of Child (1) missing LIC 627, Immunization card, PM286 and LIC 9227 and Child (4) missing LIC 627. LPA observed current safe sleep log for infant in care. LPA observed LIC282 in children's files. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and licensee's assistant.


Supervision of children was discussed with licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understand that she cannot have more than 14 children in the home at any time. Licensee stated she does 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.

LPA discussed the safe sleep regulations with licensee Maria Elena Dominguez and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

LPA also informed licensee Maria Elena Dominguez 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.

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SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, MARIA ELENA
FACILITY NUMBER: 274414151
VISIT DATE: 05/22/2024
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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/.

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

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.

Exit interview conducted and report was reviewed with the licensee Maria Elena Dominguez in Spanish.


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

The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/22/2024 01:24 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
SAN JOSE CC RO, 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: 05/22/2024

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 observed licensee CPR and First Aid Certification expiring on 04/13/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will submit proof of CPR and First Aid for licensee to SJRO by the end of the due date 06/05/2024.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in licensee’s assistant missing Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will submit proof of Mandated Reporter Training for assistant to SJRO by the end of the due date 06/05/2024.
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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 05/22/2024 01:24 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
SAN JOSE CC RO, 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on boservation and record review, the licensee did not comply with the section cited above in licensee's assistant missing LIC 9052 Notice Employee Rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will submit proof of a signed LIC 9052 for assistant to SJRO by the end of the due date 06/05/2024.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 Child (1) missing immunizations card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will submit proof of Immunization card for Child (1) to SJRO by the end of the due date 06/05/2024.
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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 05/22/2024 01:24 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
SAN JOSE CC RO, 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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 Child (1) missing PM 286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit proof of Child (1) complete PM 286 to SJRO by the end of the due date 05/29/2024.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 Child (1) and Child (4) missing LIC 627 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit proof of LIC 627 for child (1) and child (4) to SJRO by the end of the due date 05/29/2024.
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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 05/22/2024 01:24 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
SAN JOSE CC RO, 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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3
4
Based on record review, the licensee did not comply with the section cited above in Child (1) missing LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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2
3
4
Licensee will submit proof of LIC 9227 for child (1) to SJRO by the end of the due date 05/29/2024.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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