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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403705
Report Date: 05/10/2019
Date Signed: 05/10/2019 04:47:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GOMEZ, LOURDES & VICTORFACILITY NUMBER:
434403705
ADMINISTRATOR:GOMEZ, LOURDES & VICTORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 445-8590
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 6DATE:
05/10/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Lourdes GomezTIME COMPLETED:
04:50 PM
NARRATIVE
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LPA Janet Tse met with licensee Lourdes Gomez for a Case Management inspection for the type A deficiency cited on 04/24/2019. LPA explained the nature of today's inspection to Licensee. At arrival, Licensee was not home; and LPA observed five children including one infant with Licensee's assistant (EM). Licensee returned later with one school age child around 3:15pm.

At arrival, LPA observed two toddlers around two years of age standing in an enclosed area of size 4' x 4' with no toys or activities. Licensee stated that her assistant placed the children in the enclosed area after Licensee left to pick up the school age child. The children were in the enclosed area without activities for about 5 minutes or more.

LPA observed the notice of site visit with the type A deficiency cited on 04/24/2019 were posted. The written plan of correction was received by LPA on 04/24/2019. The child care home is operating within ratio and capacity today. LPA reviewed children's files and observed the LIC 9224 Acknowledgement of Receipt of Licensing Reports with parents' signatures are in each child's file. A copy of the current roster was provided to LPA today.

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Deficiency was cited. Notice of site visit was issued and must be posted with type A deficiency cited for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, LOURDES & VICTOR
FACILITY NUMBER: 434403705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2019
Section Cited
CCR
102423(a)(2)
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Personal Rights. Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to: To receive safe, healthful, and
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The enclosed area shall be used only for infants who are not mobile or old enough to climb over. The toddlers shall conduct their activities in the play area with supervision. Licensee shall forward a written plan of correction to LPA by 05/13/2019 due date, regarding the areas and accomodation for activities for the day care children.
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comfortable accommodations, furnishings, and equipment.
This requirement was not met as evidenced by:LPA observed two toddlers standing in an enclosed area of size 4' x 4' with no toys or activities.
This poses an immediate risk to the Health, Safety, or Personal Rights of children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
LIC809 (FAS) - (06/04)
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