426210992-11-23-2021-17-CC-GRES-C9322N-20211123160102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426210992
Report Date: 11/23/2021
Date Signed: 11/23/2021 04:01:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	GOMEZ FAMILY CHILD CARE		FACILITY NUMBER:	426210992
ADMINISTRATOR:	MARIA RAQUEL GOMEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 693-0768
CITY:	LOS OLIVOS	STATE: CA	ZIP CODE:	93441
CAPACITY:	14	CENSUS: 5	DATE:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Maria Raquel Gomez		TIME COMPLETED:	04:10 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 November 23, 2021 @ 11:31 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced 1 Year Required Inspection. LPA asked Covid-19 screening questions prior to inspection. LPA met with Licensee Maria Raquel Gomez and discussed the purpose of the inspection. Licensee provided LPA a tour of the facility inside and out. There were five (5 ) children present during the inspection. During the tour LPA observed the following, required forms are posted in the prominent location. Appropriate fire extinguisher was purchased on 9/06/2021 The FCCH is operated and located in a 1.5 acre ranch. At 12:00 PM smoke and carbon monoxide detectors were tested and found functional. Toxins and detergent are locked inaccessible to children in care. LPA observed clean, safe and age appropriate toys. The outside play area is an open space. Licensee was reminded that visual and physical supervision is required when day care children are outside. Nobodies of water was observed. Licensee stated there are no guns and ammunition in the home. LPA reviewed the following documents, Pediatric CPR and First Aid Card expires 1/2023. Licensee completed the Mandated Reporter Training on 2/27/2021. Licensee's immunization record is complete per SB 792,. Fire and Disaster drill was not conducted and logged within the last 6 months. LPA reminded Licensee fire and disaster drill should be conducted and logged every 6 months. Children’s roster is current. LPA reviewed children records. The records were current, complete and possessed emergency contact information as mandated by regulations.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GOMEZ FAMILY CHILD CARE	FACILITY NUMBER: 426210992
	VISIT DATE: 11/23/2021

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 Home 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

LPA discussed current Safe Sleep and Covid-19 requirements with Licensee.
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.

During today's inspection deficiencies were cited under California Code of Regulation Title 22 Division 12. Deficiencies are documented under LIC 809 D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GOMEZ FAMILY CHILD CARE	FACILITY NUMBER: 426210992
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Family Child Care Hoime failed to conduct Fire and Disaster drill every 6 months.
	POC Due Date: 11/24/2021
	Plan of Correction
1 2 3 4	Licensee agreed to conduct the Fire and disaster drill by 11/24/2021 and conducts and documents the drill every six months thereafter.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GOMEZ FAMILY CHILD CARE	FACILITY NUMBER: 426210992
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (interview) (record review), the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to conduct and document the fire and disaster drill as required.
	POC Due Date: 11/24/2021
	Plan of Correction
1 2 3 4	Licensee agreed to conduct Fire and Disaster Drill by 11/24/2021 and document the same. Licensee shall ensure that drill conducted every 6 mionths shall be documented.

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

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