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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354413862
Report Date: 11/21/2019
Date Signed: 11/21/2019 01:54:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GOMEZ, ELISAFACILITY NUMBER:
354413862
ADMINISTRATOR:GOMEZ, ELISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 630-0352
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 5DATE:
11/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elisa GomezTIME COMPLETED:
02:00 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Elisa Gomez for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee and licensee's 13 year old son and 5 day care children. Three children arrived 45 minutes later ages 8 and 7 years old. Days and hours of operation are Monday to Friday, 6:00am to 5:00pm. The adults that reside in the home are licensee, her husband, her mother with her 13-year-old son.

A review of staff records on 11/08/2019 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 understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace in the home. 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. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom and bath, 2 bedrooms and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: left and right side of home that is fenced off to children. Licensee states there are no animals in the home.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, ELISA
FACILITY NUMBER: 354413862
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2019
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement was not me as evidenced by LPA observed child 1 is missing from the roster.
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This violation poses a potential Health and Safety risk to children in care.
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Type B
12/05/2019
Section Cited

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Parent's Rights
This requirement was not me as evidenced by Child 3 is missing a signed LIC995A, Parent's Rights.
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This violation poses a potential Health and Safety risk to 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GOMEZ, ELISA
FACILITY NUMBER: 354413862
VISIT DATE: 11/21/2019
NARRATIVE
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LPA observed licensee has current CPR and First Aid certification which expires 07/04/2021. Licensee has not completed Mandated Reporter training and will complete when available in Spanish. Licensee states day care is insured with DCI. LPA discussed SB792 Immunization Requirements and observed licensee has immunizations against pertussis, measles and influenza on file. LPA observed child 1 is missing from the roster. LPA observe a current fire and disaster drill log which was last completed in 09/10/2019. LPA reviewed five children's files and observed children have current immunizations. Child 3 is missing a signed LIC995A, Parent's Rights.

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 understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. Safe sleep information & handout was also discussed with the Licensee.

The following deficiencies are cited on the attached page (809-D). Appeal rights were provided to the Licensees prior to the conclusion of today's inspection. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3