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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310791
Report Date: 06/14/2023
Date Signed: 06/15/2023 04:17:45 PM


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:GOMEZ-ZUNIGA, INESFACILITY NUMBER:
304310791
ADMINISTRATOR:GOMEZ-ZUNIGA, INESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 606-3913
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:14CENSUS: 15DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Ines GomezTIME COMPLETED:
06:00 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. Upon arrival, an Entrance Checklist (LIC 126) was provided to the licensee Ines Gomez
Census (stated by licensee: Children Over Two: 11 (10 after DOB) Infants: 2 (4 after DOB checked) Adults Working Directly with Children: 2 Other Adults: 1 / The Facility Day care hours are 7 am-5 pm, Monday through Friday.

During today’s inspection, LPA observed children in care napping on blankets in the living room, hallway leading to the garage door and around the dinning room table. The dinning room area had a wall like stand that prevented the children from leaving the dining room. There was 3 children (infants) in the living room area laying on the floor with blankets. Piano music was playing in the living room. The assistant stepped out while licensee spoke with the LPA. The licensee was left with 14 children children and after touring the bathroom the assistant stated that two children had left. LPA counted 13 children shortly after. LPA requested for the licensee to name all the children in care and 14 names were given and licensee and assistant stated 2 children left.

Posted Requirements were reviewed during todays visit. Upon arrival, the LPA verified that the following documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’ Rights, and LIC 9148 Earthquake Preparedness. The following documents are not in a prominent and public area that can easily bee seen by parents. A consultation was provide and a copy of the earthquake prepares was provided.

Facility Tour of the inside and outside area was conducted during today's inspection. The LPA and licensee toured the facility inside and outside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility sketch were made off limits by a baby safe gate going up stairs. There is a fireplace in the living room screened by metal bars.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 06/14/2023
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Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available to children were not observed to be out or accessible. The licensee was given a consulted on the importance of making sure latches work in the kitchen or to block off the kitchen area. Licensee stated there are firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.
Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary.

Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary. Children nap on blankets and bedding is stored in the closet next to the bathroom. The licensee washes the blankets at home. All soiled blankets and clothing are washed right away stated by the licensee.

The licensee stated the children's primary care and play areas consist of dinning room and living room stated by the licensee. The home has some age-appropriate toys for the ages served in the living room and a consultation was provided.

Outdoor/Play Yard was toured at 2:55pm: The cushioning material used at the facility consists of matts stated by licensee but none were observed. The outdoor equipment and toys were not in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility outdoor grounds were safe, sanitary, and in good repair. LPA observed various spider webs, cactus plants, neem oil, glass doors (not installed), outdoor bead bags, and other items that can pose danger to children.

Identify Location & Functioning of the carbon monoxide, smoke detector and fire extinguisher were reviewed. The fire extinguisher is on the wall next to the closet and stairs. The smoke detector was tested and functional.

Records Reviewed: The LPA requested to review the LIC 610A Emergency Disaster Plan, Verification of Disaster and Fire Drills, and LIC 9040 Facility Roster. The licensee provided the LPA a sheet of paper with two dates on it and last drill conducted was stated to be on JAN 7 2023 and May 18, 2023. The licensee met the requirements during the inspection and LPA reminded the licensee of the importance of keeping documents up to date to comply consistently.

Personnel Records:were revied during today's inspection at 3:08 pm. The LPA requested completed personnel records of 2 of 2 adults working with children today.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 06/14/2023
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The following documents were reviewed in the files provided by the licensee; CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate. No mandated reporter for assistant 1-3.

Children’s Records Reviewed at 3:14 pm:The LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was separate, complete, and current record for each child. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identification and Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. The licensee gave the LPA 13 of 15 file. Children's records were not complete.

Individual Sleep Plans and Sleep Logs:LPA observed (# of infants) from 0-24 months. 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 maintained at the facility in the infant’s file. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan in children’s files. LIC 9227 was reviewed in files 1 of 3 children have a completed document and no sleep logs were available for review.

During today’s inspection, the licensee and LPA discussed the following:

- Stay up to date with LIC 9227 and discuss with parents any new changes


- Ensure 15 min checks are conducted & logged (The initial of the person checking should be included)
- 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.
- Always place infants on their backs to sleep
- Use only a tight-fitting sheet on the crib or play yard mattress
- Do not hang any items from the crib or above the crib
- Keep all items, including blankets, out of the crib or play yard
- Pacifiers may be used if they do not have items attached to them
- Infants should not be swaddled or have any items covering them while sleeping
- The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 06/14/2023
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The following are additional resources.
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
The American Academy of Pediatric https://www.aap.org/en/patient-care/safe-sleep/
Safe Sleep Regulations https://cdss.ca.gov/Portals/9/Additional-Resources/Legislation-and-Regulations/Public%20Hearing%20Docs/f031803RegulationsTextOALfinal.pdf

Background Checks :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 or exemptions. Currently, there are 4 adults including the licensee and 0 minor child living in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance. The licensee was also reminded that any children turning 18 years must obtain a background check to maintain compliance.

LPA provided Guardian Information and website info:


https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Video: https://ccld.childcarevideos.org/family-child-care-providers/background-check-requirements-for-caregivers/
CCLD website www.ccld.ca.gov was provided to licensees to access regulations, updates, and licensing forms.

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 06/14/2023
NARRATIVE
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Child Care Licensing Program Webinars: The Child Care Licensing Program is pleased to continue offering webinars to share important information with the child care licensing community in 2023.
2023 Webinar Schedule
• Tuesday, June 27, 2023, 6:00 p.m.
• Tuesday, September 26, 2023, 6:00 p.m.
• Tuesday, December 12, 2023, 6:00 p.m.
To register for webinars, see Provider Information Notice (PIN), PIN 22-30-CCP. Providers may wish to view previously recorded webinars.
• Child Care Licensing Program Provider Webinar (Nov/Dec 2022)
• Child Care Licensing Program Provider Webinar (October 2022)
• Child Care Licensing Program Provider Webinar (September 2022)
• Child Care Licensing Program Provider Webinar (August 2022)

Children and Car Safety: Leaving infants or children unattended in a parked car can have disastrous consequences, as the temperature inside a vehicle can rise quickly, even with a cracked window. Before leaving a vehicle, it is crucial to double-check that everyone has exited and to check the backseat for any children who may have fallen asleep. To avoid forgetting a child in the car, caregivers can place a stuffed animal in the front seat as a reminder and best practice suggestion. Providers are reminded that you are responsible for the care and supervision of children during transportation regardless of the vehicle type (car or van). It is recommended that providers create, educate, and enforce policies and practices to ensure the safe transportation of children in care.

Heat Precautions in Child Care: Health and age play a significant role in how people react to extreme heat. Individuals at most significant risk for heat-related illness include infants and children up to four (4) years of age. By knowing how to prepare for a heat wave, and what to do when one occurs, you can avoid the biggest health dangers, such as heat exhaustion and heat stroke. Before sending children out to play, adequate supervision is required and staff need to know how to protect them against heat-related illness. Providers must meet the requirements of the applicable HSC, Child Day Care Act, Sections 1596.70 et seq., and California Code of Regulations, Title 22, Division 12. Have a safe, healthy, and enjoyable summer!
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791
VISIT DATE: 06/14/2023
NARRATIVE
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The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for 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.

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 visit.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today:

CCR102352(p)(2), CCR102417(g), CCR102425(a), CCR102416.5(a), CCR102416.5(d)(2), CCR102425(j)(2), HSC1596.8662(b)(1), CCR102425(c), CCR102425(j)(2)(D), CCR 102423(a)(2)

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day and shall provide them to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt of the Proof of Correction for 30 consecutive days.
An exit interview was conducted with 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 at 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.

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/inspection-process
End of Report.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 16
Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102352(p)(2)
Definitions
(2) "Play Yard" means a framed enclosure with integrated mesh or fabric sides that has not been banned or recalled by the United States Consumer Product Safety Commission.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAobservation, and licensee interview, the licensee did not comply with the section cited above by means of not having a safe place for infants to sleep in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee pulled out a play yard for infants to begin sleeping in as of tomorrow.
Type A
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and licensee interview the licensee did not comply with the section cited above by means of latches in the kitchen being broken and accessible, and other dangerous items in the backyard that are accessible to children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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The licensse states she would fix it and send picture to LPA email.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 7 of 16


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by means of not have a play yard or crib for infants in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee stated she would have this available for infants as of tomorrow.
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, licensee interview and record review, the licensee did not comply with the section cited above b y means of being over capacity/ ratio which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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The licensee stated she will be speaking with the parent of one child to meet ratio.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 8 of 16


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(2)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review , the licensee did not comply with the section cited above due to having 9 preschool children, 1 school age and 4 infants which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee stated she would be speaking with a parent to cancel services and meet ratios.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 9 of 16


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by means of not having sleep logs for LPA to review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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2
3
4
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 LPA observation, licensee interview and record review, the licensee did not comply with the section cited above by means of not having a certificate for the assistants in her facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2023
Plan of Correction
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The licensee is going to have her assistant and husband take the training.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 10 of 16


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

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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Based on record review, the licensee did not comply with the section cited above by means of not having this document in file for 1 of 1 children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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The licensee will be making copies and give it to the parents to complete.
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 by means of missing documentation for infants files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee stated that she will have documentation in file once completed.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 11 of 16


Document Has Been Signed on 06/15/2023 04:17 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: GOMEZ-ZUNIGA, INES
FACILITY NUMBER: 304310791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and licenssee interviewthe licensee did not comply with the section cited above by means of not having a crib or play yard for infants to sleep in posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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Licensee brought out the play yard children will begin using as of tomorrow and stated she had two for children 0-12 months to use.
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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 12 of 16