426215912-4-11-2022-17-CC-GRES-CDDU7H-20220411151958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 426215912
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:20:04 PM

Document Has Been Signed on 04/11/2022 03:20 PM - 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, 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: 4	DATE:	04/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Liliana Gomez		TIME COMPLETED:	03:20 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 April 11, 2022 at 12:21 PM , Licensing Program Analyst Gigi Reyes conducted an unannounced required one (1) year inspection at the above Family Child Care Home (FCCH) LPA asked pre screening questions related to COVID- 19 and licensee’s responses indicate there are no COVID 19 exposures on site. LPA met with Licensee Liliana Gomez and discussed the purpose of the inspection. There were 4 children present during the inspection. LPA in the company of Licensee toured the interior and exterior of the day care. FCCH has a dedicated room for childcare where all day care activities are held. The day care area is secured with gate making the dining room, kitchen, living room and bedrooms inaccessible to day care children. The bathroom used by children is located outside the gated day care area, Licensee stated she accompanies the child to the bathroom LPA observed required licensing forms are posted in the FCCH posted in the wall. LPA observed smoke and carbon monoxide detectors in the FCCH. The regulation fire extinguisher was purchased on 1/6/2022. The backyard is enclosed by 6 ft. brick wall. Day care play area is enclosed with chicken wire separating it from the whole backyard. LPA observed a locked trampoline in the backyard. Licensee stated day care children do not use the trampoline. No bodies of water were observed on site. Licensee stated there are no guns or ammunition in the home LPA Reyes reviewed facility file, Pediatric CPR and First Aid expires on 11/8/2023. Licensee's mandated reporter training certificate expired on 2/5/2022. Licensee was reminded that the said training certificate should be renewed every two years. Licensee has proof of immunization on file. Licensee stated she supervises sleeping infants every 15 minutes, however, it was not documented. FCCH has current roster of children in care. Children's records were reviewed, children's files contain Emergency and Identification card requirements. . . Based on LPA review, Infant # 1 who was 9 month during the enrollment (on 1/30/2022) has no Individual Safe Sleep Plan (LIC 9227) on file. Continued on 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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

FACILITY NAME: GOMEZ FAMILY CHILD CARE	FACILITY NUMBER: 426215912
	VISIT DATE: 04/11/2022

NARRATIVE

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During today's inspection, deficiencies were cited under Title 22 Division 12 and Technical Violation was issued.

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 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.
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.

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

Exit interview conducted and report was reviewed with the licensee, Liliana Gomez

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2022 03:20 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, mandated reporter training certificate expired on 2/5/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2022
	Plan of Correction
1 2 3 4	Licensee agreed to renew the mandated reporter training and submit the certificate to Community Care Licensing (CCL) no later than 4/21/2022.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review and interview], the licensee did not comply with the section cited above, licensee stated she was checking and supervising sleeping infant every 15 minute but there was no documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit the proof and correction (POC) ensuring that licensee will document the 15 minute checking of the napping infant and will maintain the documentation on file. POC will be submitted to CCL no later than 4/21/2022

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: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC809 (FAS) - (06/04)

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