414004590-8-25-2021-05-CC-CQUO-C68LZL-20210825091206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004590
Report Date: 08/25/2021
Date Signed: 08/25/2021 09:12:35 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: 2	DATE:	08/25/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:			TIME COMPLETED:	09:30 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	On August 25, 2021 at 8:15am, Licensing Program Analyst (LPA) Catrina Quimbo met with licensee, Karla Gomez, for a scheduled case management inspection. At time of inspection, present in the home is licensee and 1 enrolled child (1 preschooler). All adults living and working in the home have criminal background clearance on file. Licensee is currently licensed for a capacity of 8 children in current facility. Licensee requested to add garage as part of the day care area. LPA and Licensee inspected home for health and safety hazards. Hours of operation are Monday to Friday 8:30am to 4:00pm. Licensee owns home with husband. Licensee lives in single level home with husband. Home consists of 3 bedrooms, 2 bathrooms, 1 living room, dining area, kitchen, backyard and garage. Day care areas now approved are: bedroom #1 (baby room), bathroom #1 (located next to kitchen), living room, kitchen, dining area, garage and front area of backyard area. OFF limit areas are: bedroom #2 (guest room), bedroom #3 (master bedroom), bathroom #2, and back part of backyard area. All off limits areas are made inaccessible to children by locked doors. At 8:40am, 1 infant arrived at facility. Present during inspection is licensee and 2 enrolled children (1 infant and 1 preschooler). (Continue on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 393-8293
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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

FACILITY NAME: GOMEZ, KARLA	FACILITY NUMBER: 414004590
	VISIT DATE: 08/25/2021

NARRATIVE

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LPA observed home to be in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which are in good condition. All electrical outlets accessible to children have child safety covers. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Cabinets and drawers throughout the home have child safety locks. All sharp edges are properly padded. Living room area leading to garage contain 3 steps. Licensee has placed a child safety gate at the top of the steps. Garage contains washer and dryer, blocked by furniture, made inaccessible to children in care. Fire extinguisher is fully charged and accessible. Home has a functioning smoke and carbon monoxide detectors.

Discipline policy, COVID-19 guidelines and updated safe sleep regulations were discussed. Licensee was reminded to document safe sleep logs for napping infants, conduct emergency drills once every six months and to renew Mandated Reporter training every 2 years. Licensee was advised to check CCLD website for any updates and/or provider information notices (PINs).

After today’s inspection, an exit interview was conducted with licensee, Karla Gomez. This report is public and can be reviewed. Copy of this report was provided to licensee at swissarmy68@yahoo.com. Licensee were advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 393-8293
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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