283004528-11-29-2023-01-CC-CCAO-CY2SAR-20231129124246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 283004528
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:43:04 PM

Document Has Been Signed on 11/29/2023 12:43 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	DOMINGO, GUADALUPE FAMILY CHILD CARE HOME		FACILITY NUMBER:	283004528
ADMINISTRATOR:	DOMINGO, GUADALUPE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 557-6334
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	14	CENSUS: 7	DATE:	11/29/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Guadalupe Domingo- Licensee		TIME COMPLETED:	12:45 PM

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A required inspection was made to the facility by Licensing Program Analyst (LPA), Cindy Castro. LPA met with Licensee (L1), Guadalupe Domingo. L1 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, a maximum of 30 days per person will be assessed if this regulation is violated.

During the inspection the home was toured inside and outside. The licensee was supervising 7 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:00 AM-5:30PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. Children in care will have access to family room, dining room, kitchen, one bathroom, and the backyard which is fenced. The "off limits" areas include the main living room, the garage, the second floor of home and the pool in the backyard. These areas were observed to be made inaccessible by child safety latches, child safety gates, pool gate, pool cover and window in main living room key locked at all times during child care hours. The children use the backyard as the outdoor play area. There is a pool in the backyard that is fenced and has a pool cover. There is a pool waiver on file for facility granted on 08/11/2017. The home appears to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. L1 stated poisons were locked in the storage shed in backyard. LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home.

Continued on LIC 809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Cindy Castro	TELEPHONE: (707) 867-6190
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DOMINGO, GUADALUPE FAMILY CHILD CARE HOME	FACILITY NUMBER: 283004528
	VISIT DATE: 11/29/2023

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The electric fireplace has been made inaccessible with a screen. Licensee stated she does not use the fireplace at all. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months; last drill was documented on 11/03/23. The licensee’s pediatric CPR and First Aid certifications were reviewed, and expire on 04/2025. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. Five children's records were reviewed and contained required documents. Facility and personnel files were reviewed and contained required documents.

LPAs discussed the safe sleep regulations and left a copy 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.

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/.

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.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Cindy Castro	TELEPHONE: (707) 867-6190
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DOMINGO, GUADALUPE FAMILY CHILD CARE HOME	FACILITY NUMBER: 283004528
	VISIT DATE: 11/29/2023

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

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.

There were no Title 22 deficiencies cited during today's inspection.

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Guadalupe Domingo.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Cindy Castro	TELEPHONE: (707) 867-6190
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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