376628572-8-5-2021-20-CC-ECAA-C5LV47-20210805160552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376628572
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:06:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	GOMEZ, CINTHYA FAMILY CHILD CARE		FACILITY NUMBER:	376628572
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 8	DATE:	08/05/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cinthya Gomez, Licensee		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On August 05, 2021, at 2:00 PM, Licensing Program Analyst (LPA), Edgar Campana conducted an unannounced case management inspection with licensee, Cinthya Gomez. LPA Campana notified licensee the purpose of the inspection was the requested change of capacity. Licensee led LPA on a tour of the facility. There were 8 children (two of whom are infants) as well as Licensee's adult son who is cleared and associated. During tour of facility, LPA observed one infant sleeping on the floor, and not in an approved crib or play yard. Deficiency cited, see LIC809-D. On 07/20/2021, a fire clearance was approved for 14 children. Licensee will use the following areas for child care: living room 1, living room 2, downstairs bathroom, and backyard. The following areas are off limits: garage, kitchen, and entire second floor (4 bedrooms, 2 bath). Off limits are all made inaccessible via safety gates and door knob covers. There are no bodies of water observed during time of inspection. There are sufficient age appropriate toys, games, and books available. The home was clean and orderly during inspection. The fire extinguisher is rated 2-A;10; BC, smoke alarm and carbon monoxide detector are operational. The is a working telephone in the home and all required forms are posted. Licensee stated that there are NO firearms or ammunition on the property. All adults living or working in the home have been fingerprint cleared and associated. LPA reviewed children's files and emergency drill log. LPA reviewed the facility roster. Last fire/disaster drill was conducted 07/05/2021. Pediatric CPR and First Aid certification expire 12/2021. LPA discussed with Licensee maintaining supervision of day children at all times. LPA reviewed the following with licensee: SIDS, car seat law, reporting requirements, shaken baby syndrome, care and supervision, safe sleep regulations, and COVID-19 precautions/guidelines. Licensee was also reminded the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GOMEZ, CINTHYA FAMILY CHILD CARE	FACILITY NUMBER: 376628572
	VISIT DATE: 08/05/2021

NARRATIVE

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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.html

The maximum capacity for a large family child care home: 12 children (with a qualified assistant) with no more than 4 infants; or (with landlord consent) 14 children (with a qualified assistant) with no more than 3 infants, 1 child enrolled in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. When there is no Qualified Assistant, 14 years of age or present, the capacity reverts back to the requirements for a Small Family Child Care. To access our Regulations and Forms please use our WEBSITE: http://ccld.ca.gov.

A copy of the case management report, Notice of Site Visit – LIC 9213 and appeal rights (LIC 9058) was provided to the licensee.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

A Regular Large Family Child Care Home license may be issued for 14 children upon final file review.

SUPERVISOR'S NAME: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GOMEZ, CINTHYA FAMILY CHILD CARE	FACILITY NUMBER: 376628572
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/06/2021 Section Cited	1 2 3 4 5 6 7	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:
	8 9 10 11 12 13 14	Based on observations, Licensee did not ensure that there is one crib or play yard for each infant, which poses a possible risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Jason Garay	TELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Edgar Campana	TELEPHONE: (619) 767-2208
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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