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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312270
Report Date: 07/19/2019
Date Signed: 07/19/2019 12:11:10 PM

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, LAURA SILVIAFACILITY NUMBER:
304312270
ADMINISTRATOR:GOMEZ, STRATHMORE SILVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 923-9182
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:14CENSUS: 12DATE:
07/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Laura GomezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ho and licensee toured the facility inside and outside. LPA observed 7 preschool age children and 5 school-age children playing outside. The facility was within licensed capacity and the required ratio. Also, present assisting with the day care was licensee’s assistants Mariana Dzib and Adrina Morales. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is a single story home with three bedrooms and 2 baths. LPA observed a gate installed at the bottom of the stairs to prevent the children from accessing into the second floor. Licensee stated off limit areas include: all bedroom. Licensee acknowledged that children may never enter these off-limit areas. Family members residing at facility are 2 adults and 1 child. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Per Licensee there are no weapons, firearms in the facility at this time. Anytime when firearms were present in the facility, they must be locked and inaccessible to children. The ammunition must be locked and separate from the firearms. LPA observed a swimming pool on the premises and it met all licensing requirements. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. Facility roster, disaster drill, and staff's Mandated Reporter Training certificates were available for review. Staff's required immunization (MMR, TDAP, FLU) were not available for review. The licensee was reminded that must present at facility and ensure that children are properly cared for and supervised at all times. The licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time. All day-care activities take place in the living room, kitchen, and dining area. Children are able to have outside play in the enclosed front and backyard. Licensee is current with Pediatric CPR and First Aid and both valid until 3/9/2021.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
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, LAURA SILVIA
FACILITY NUMBER: 304312270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2019
Section Cited
HSC
1597.622(a)(1)
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Employee and Volunteer Immunization (1) Commencing September 1, 2016, a person shall not be employed...family day care home if he or she has not been immunized against influenza, pertussis, and measles...This requirement was not met as evidenced by: Based on record review. 3 staff files reviewed and all 3 files were missing proof of Pertussis,
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Licensee stated she and her assistants will take the required shots. Proof will be sent LPA Ho by 8/16/19.
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Measles, and Flu vaccines. The licensee failed to ensure to maintain licensee immunization records. This poses a potential Health and Safety risk to the children in care.
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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: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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, LAURA SILVIA
FACILITY NUMBER: 304312270
VISIT DATE: 07/19/2019
NARRATIVE
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Licensee does not provide Incident Medical Services.

The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, No Johnny jumpers, no exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby.

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

After a tour of the home and review children and staff's records, the following deficiency was observed and cited in accordance with Title 22, Division 12, Chapter 3 of Family Child Care Homes. Please refer to attached 809D for documentation of deficiencies.

During exit interview, “The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.” Notice of Site Visit was posted. Licensee was informed to keep the Notice of Site Visit posted for 30 days during the daycare hours or $100 civil penalty will be assessed.

LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· 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 as long as 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
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