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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310791
Report Date: 11/19/2019
Date Signed: 11/19/2019 10:46:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GOMEZ-ZUNIGA, INESFACILITY NUMBER:
304310791
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
11/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Ines Gomez-Zuniga TIME COMPLETED:
11:00 AM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Connolly. LPA observed licensee caring for 6 children which included 1 infant and 5 preschool age. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. Currently there are 4 adults including the licensee living in the facility.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of a gate at the bottom of the staircase leading to the second story of the home and door grips on the door handles of the doors leading to areas of the home not designated for day care purposes such as the garage and laundry room. Licensee said the primary areas of day care are the dining room for the napping of children, living room serving as a play room and downstairs hallway bathroom.

There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There is a fireplace in the living room screened by metal grating and inaccessible to children in care. The home has age appropriate toys for the ages served. During today’s inspection LPA observed the licensee's health cards have expired. The licensee does have a current roster of children in care. LPA verified there is a working telephone service. LPA reviewed children files to ensure children immunizations are maintained and a copy of the Family Child Care Home Notification of Parents' Rights have been provided to child's parents or representative. Continued on page two
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 11/19/2019
NARRATIVE
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page two
There were no poisons or other items observed which could pose a danger to children.

The licensee has designated the fenced back yard as the area for outdoor play by children in care. Licensee said the outdoor climbing equipment has cushioning underneath and surrounding when children in care are playing in this outdoor designated play area. Licensee said when children in care are in this area 100% visual supervision is provided. There are no bodies of water on the premises.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee were reviewed.

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
Licensee said there are no incidental medical services being provided at this time.

The licensee understands she must be present in the facility and must ensure children in care are supervised at all times and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.
Continued on page three
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 11/19/2019
NARRATIVE
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A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the inspection. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Operation of a Family Child Care Home ,102416(c) and HSC 1597.622.

An exit interview conducted with the licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2019
Section Cited

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 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

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regulation is not met as evidenced by licensee presenting health cards with expiration date 8/26/19. Expired health cards pose a potential threat to the health and safety of children in care.
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Type B
12/16/2019
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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The licensee did not have proof of immunization against measles and Pertussis available for review. This is a potential threat to the children's health and safety.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2019
LIC809 (FAS) - (06/04)
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