414004590-2-18-2022-05-CC-CQUO-CBRQ4F-20220218105017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004590
Report Date: 02/18/2022
Date Signed: 02/18/2022 10:50:43 AM

Document Has Been Signed on 02/18/2022 10:50 AM - It Cannot Be Edited

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:	02/18/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karla Gomez		TIME COMPLETED:	11:00 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 February 18, 2022 at 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted a case management, capacity increase inspection. LPA met with licensee, Karla Gomez, and explained the purpose of the inspection. Present in the home were licensee, licensee's spouse, and 2 enrolled children (1 infant and 1 preschool age). Licensee is operating within capacity limits and ratio on this date. All adults living and/or working in the home have fingerprint clearance on file. Licensee is currently licensed for a small family child care home and applied for a large family child care home license on 01/03/2022. Licensee obtained a fire clearance and was approved 02/11/2022. Hours of operation are Monday to Friday from 8:30am to 5:30pm. At approximately 9:15am, LPA inspected the entire home for health and safety hazards. The home is a single-level, family home that consists of three bedrooms, 2 bathrooms, living room, kitchen/dining area, backyard, front yard and garage. The DAY CARE AREAS are bedroom #1 (napping room only), bedroom #2, bathroom # 1 (located next to kitchen), living room, kitchen/dining area (pass-by only), backyard, front yard and garage. The OFF-LIMIT AREAS are bedroom #3 and bathroom #2. All off limit areas are properly barricaded with locked doors. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of age appropriate toys that were in good condition. Outdoor area is equipped with age appropriate toys and materials that were also in good working condition. There were no pools, spas or bodies of water on the property. All cleaning supplies, poisons, other chemicals, and sharp objects were stored inaccessible to children behind child safety locked cabinets and drawers. Accessible electrical outlets have child safety covers and/or are blocked by furniture. (Continue Report on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

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: 02/18/2022

NARRATIVE

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LPA observed a fully charged fire extinguisher and a working fire alarm system, installed in the home. There is a smoke/carbon monoxide detector and working phone on site. Licensee uses a designated cell phone and is aware the phone must remain in the home during hours of operation.

LPA reviewed capacity limits and ratios for both a small and large license with licensee. LPA reminded licensee that an assistant must be present when the licensee is caring for the maximum number of children the large license allows for. LPA reminded licensee that when licensee is working alone, the licensee must follow the small license requirements.
LPA reminded licensee baby walkers, bouncers, jumpers and any other similar items are not to be used for children in care.

LPA reminded licensee of PIN 20-24-CCP Safe Sleep Regulation, CA DPH Guidance for use of face coverings, and receiving important updates. Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.

Licensee's Mandated Reporter training is current and will expire 02/2024. Licensee's CPR and First Aid is current and will expire 02/2023.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

After today’s inspection, an exit interview was conducted with licensee. No deficiencies were cited as part of today's inspection.

A large license has been granted and effective on this date.

A Notice of Site Visit will be given and must remain posted for 30 days.

This report was reviewed and discussed with Licensee, Karla Gomez.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

LIC809 (FAS) - (06/04)

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