426215912-3-2-2020-17-CC-EBAY-BMBPQF-20200302103104

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426215912
Report Date: 03/02/2020
Date Signed: 03/02/2020 10:31:48 AM

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:	426215912
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 1	DATE:	03/02/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Liliana Gomez		TIME COMPLETED:	10:20 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 March 2, 2020, at 8:20 AM, Licensing Program Analyst (LPA) Elvin Baddley made an announced visit to conduct a Pre-Licensing Inspection for the abovementioned home. LPA met with Liliana Gomez, the applicant of the home and explained the nature and purpose of the inspection. The Applicant's child (22 months) was on site at the time of the inspection. In the company of the applicant, LPA toured the interior and exterior of the home. The home is a three bedroom, two bath single dwelling. Applicant stated the home’s sun room, backyard and hallway bathroom will be used for child care, while the home’s bedrooms, garage, and master bathroom will be excluded/off limits. LPA observed the home to be orderly. LPA observed a fireplace in the home's family room which was screened with a mesh covering and inaccessible to children. The bathroom to be used for children care was observed to be clean and free of toxins. Medication and sharps in the home are stored on elevated shelves in the kitchen's cabinets. Detergents and cleaning compounds are stored on an elevated shelf in the laundry/wash room. The area where the detergents and cleaning compounds are stored are beyond the reach of children. LPA observed a combination carbon monoxide/smoke alarm detector affixed to the hallway wall. The detector was tested and found to be inoperable. LPA reminded the Applicant Family Child Care Homes (FCCH) must maintain operable carbon monoxide and smoke alarm detectors. LPA observed a fire extinguisher on site which was purchased on February 29, 2020. LPA observed required licensing forms and documents posted near the home's entry door. An electric socket plate was observed missing in the sun room. LPA reminded Applicant electric socket plated need to be in place prior to licensing. The outdoor play area is enclosed by cinder block fencing. The backyard is partitioned to divide the area of child care from an area of personal use. A fence dividing the two areas is incomplete. LPA reminded the Applicant fencing needed to be completed before child care could commence. No bodies of water were CONT. 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2020

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: 426215912
	VISIT DATE: 03/02/2020

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observed on site.
The Applicant completed AB 1207 Mandated Reporter training on January 28, 2020. Further, the applicant completed Preventative Health training on February 22, 2020. Applicant’s Pediatric CPR and First Aid certificate expires on November 16, 2021. Applicant informed LPA no firearm or ammunition is stored on site. LPA reviewed a Grant Deed for the property. Applicant states the home does not have liability insurance. LPA informed applicant parents will need to sign a waiver for the liability insurance (applicant was provided form-LIC 282).

Applicant is not providing Incidental Medical Services. Incidental Medical Services (IMS) policy was discussed. 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

LPA discussed AB 633 and handed Pre-licensing packet to applicant. LPA reviewed and issued the applicant updated samples of state required forms to be kept in the children's record. LPA also discussed and provide the applicants Guidelines to Safe Sleep and Effects of Lead Exposure leaflets. Applicant was informed that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours. Applicants were made aware of the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

Licensure is pending the following:

1. Operable Smoke and carbon monoxide detectors
2. Electric socket plate cover placed in sun room
3. Completion of backyard fencing (dividing exclude area from area for child care)

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2020

LIC809 (FAS) - (06/04)

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