414004590-8-21-2019-05-CC-FBRR-BF9P2K-20190821105603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004590
Report Date: 08/21/2019
Date Signed: 08/21/2019 10:56:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	GOMEZ, KARLA		FACILITY NUMBER:	414004590
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	08/21/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Karla Gomez		TIME COMPLETED:	11:15 AM

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	Licensing Program Analyst (LPA) Faye Bremer conducted an announced Prelicensing inspection. LPA met with Applicant Karla Gomez and explained purpose of inspection. Applicant rents this single-story home, with attic. The Applicant lives in this home with her husband. LPA verified documents during the visit. The entire home is inspected for health and safety hazards. There are three bedrooms, 2 bathrooms, a living room, dining room, front yard, backyard, and kitchen in this home. The home has working smoke and carbon monoxide detectors throughout the home, a working telephone, a fully charged 2A10BC fire extinguisher, first aid and emergency supplies. Day care areas are: the living room, guest bedroom, baby bedroom, the backyard, the kitchen, and the master bathroom. Off limit areas are: the master bedroom, garage, storage area in the back yard, and attic. Per Applicant, she has plans to utilize the garage for the day care in the future, but as of now it is considered of-limits. The off limits areas are blocked off and made inaccessible. Per licensee, there are no pets, no firearms or no weapons in the home. Isolation area will be the living room or the dining area. There are sufficient furniture and age appropriate toys and children's equipment in the day care areas. Home is clean and no hazardous material is accessible to children. CPR/First Aid, 16 hrs health and safety training has been completed and was current. Applicant will prepare meals for children. Applicant will provide an age appropriate curriculum. Discipline policy was discussed with applicant. Safe Sleep policies were discussed with applicant. Per Applicant, she has purchased liability insurance. Posting of Parent's Right and the Emergency Disaster Plan was discussed with Applicant, and will be posted on the wall next to the living room. Licensee was advised to post the License when she received it. Licensee was also advised to conduct fire/disaster drills at lease once every six months, and to log the date and time of the drill. Records to be maintained was discussed and reviewed with Applicant. Applicant was informed to obtain copy of regulations and current licensing forms thru the Department's website at www.ccld.ca.gov. Requirements regarding Unusual Incident Report were also discussed. Continues on next page.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Faye Bremer	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOMEZ, KARLA	FACILITY NUMBER: 414004590
	VISIT DATE: 08/21/2019

NARRATIVE

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During the visit LPA discussed IMS (Incidental Medical Service) policies with Applicant. 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.htm

Landlord notification is on file. Landlord consent, LIC9149, is not on file. The facility can only care for 6 children without landlord approval. Applicant informs LPA that she will submit the LIC9149 to her Landlord for approval, and will submit the signed LIC9149 to CCL.

LPA recommends this facility to be licensed for 6 ambulatory children today.

This report was reviewed and copy provided to Applicant Karla Gomez.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Faye Bremer	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019

LIC809 (FAS) - (06/04)

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