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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354415984
Report Date: 04/20/2021
Date Signed: 04/20/2021 11:07:02 AM

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:DOMINGUEZ, MARIA DEL CARMENFACILITY NUMBER:
354415984
ADMINISTRATOR:MARIA DEL CARMEN DOMINGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 607-1466
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:14CENSUS: 3DATE:
04/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Maria Del Carmen DominguezTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Deanna Villagrana met with applicant Maria Del Carmen Dominguez to conduct an announced change of location inspection Via Facetime due to Covid-19. The adults that reside in the home are the Applicant and her husband, applicant's mother with three children ages 10, 8 and 2 years old.

Days and hours of operation will be Monday - Friday from 7:00 AM to 5:00 PM. Applicant has completed her Preventative Health and Safety Child Care Training on including Lead training on 11/21/2020. A copy of the certificates are on file. Applicant's CPR and First Aid certifications are current and expire on 05/19/2021. Applicant completed Mandated Reporter training on 02/17/2020. Applicant's owns the home. Applicant does not have liability insurance and will issue affidavit regarding liability insurance for FCCH.

LPA toured the indoor and outdoor areas during today's visit. LPA observed a barricaded fireplace in the family room. Off limit areas inside the home: Master bedroom/bath, two bedrooms, two hallway closets, laundry/pantry room and attached garage. LPA observed a fully charged 2A10BC fire extinguisher, working combo smoke and carbon monoxide detector, fenced backyard, and no bodies of water. Off limit area in the backyard is the left side of the home that is fenced off to the children. Applicant states she has one dog that is vaccinated and several birds. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes. There are no weapons in the home.

A review of staff records on 04/20/2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record
and child abuse index clearances or exemptions. LPA reminded Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, MARIA DEL CARMEN
FACILITY NUMBER: 354415984
VISIT DATE: 04/20/2021
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provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Forms of discipline used by Applicant: talking to children and redirection. Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

A Family Child Care Home packet with updated Licensing forms was mailed to Applicant prior to visit and reviewed with the Applicant. LPA discussed the requirements of AB 633 with the Applicant and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant understands the requirements. LPA also discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. 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. SB 792 Immunization Requirements was also discussed. Applicant's immunization records are on file.

LPA conducted an exit interview with the Applicant and advised her that a large Family Child Care Home license is pending Managers approval.

This report has been emailed to Applicant and Applicant will reply to email in lieu of a signature.

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

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC809 (FAS) - (06/04)
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