<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403705
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:55:22 PM


Document Has Been Signed on 08/30/2022 03:55 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, 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: 7DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lourdes GomezTIME 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 08/30/2022 at 10:20 AM, Licensing Program Analysts (LPAs), Teodoro Trujillo and Susy Cervantes, met with Licensee, Lourdes Gomez, for an unannounced Required - 1 Year Inspection. LPAs were granted access to the home by the Licensee. Also present in the home was her assistant, Esperanza Machuca, and her adult grandson Mario Gomez with 7 children in care, 3 infants, 3 prescholl and 1 school age. LPAs observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 6:00 AM to 6:00 PM. Licensee is serving children ages 0 years to 13 years old. There are no active waivers or exceptions for this facility. Licensee states that there are four adults residing in the home: herself, her spouse, her daughter and grandson with two children ages 13 and 6.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 08/17/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee's assistant is fingerprint cleared, however they are not associated to the facility. 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 reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on May 20, 2022. LPA observed a fully charged 3A40BC fire extinguisher, wall enclosed fireplace, and functioning combination smoke and carbon monoxide detectors. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home.

Continuation on next pages:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


Document Has Been Signed on 08/30/2022 03:55 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, 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, LPA observed prescribed and over the counter medication in Hallway closet that was not locked to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
1
2
3
4
Licensee will remove and place all medication in the off limit Garage.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 08/30/2022 03:55 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, 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: 08/30/2022

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 observation and record review, the licensee did not comply with the section cited above, LPA did not observe a completed Mandated Reporter Training Certificate for licensee Victor Gomez which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
1
2
3
4
Licensee Victor Gomez will enroll and complete Mandated Reporter Training online and will submit proof of completion certificate to the San Jose Regional Office by the end of business day 09/09/2022.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, LPA did not observe proof of MMR and Pertussis immunization during file review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
1
2
3
4
Licensee Victor Gomez will submit proof of immunization for MMR and Pertussis to the San Jose Regional Office by the end of business day of 09/13/2022.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 08/30/2022 03:55 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, 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: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, LPA observed missing LIC 9227 for Child 9 during file review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
1
2
3
4
Licensee will have parent of Child 9 complete and sign LIC 9227 and submit a copy of completed form to the San Jose Regional Office by the end of business day 09/13/20222.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


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
VISIT DATE: 08/30/2022
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
26
27
28
29
30
31
32
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, 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 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

Indoor licensed areas of the facility were inspected by LPAs today and observed to be clean, orderly, and safe for the day care children. Off-limits areas in the home include: attached garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone.

The outdoor licensed areas of the home was inspected and observed to be fenced in. Off limit areas outside the home include: left and right side yards that are fenced off and contain storage sheds on both sides. There were no bodies of water observed.

Ten (10) children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records (PM286). LPAs observed Child 09 is missing LIC 9227.

Licensee Lourdes Gomez Mandated Reporter Training for Child Care Providers expires on January 27, 2024, assistant Esperanza Machuca expires on 08/14/2023 and Licensee Victor Gomez has not completed mandated reporter training. Mandated Reported Training can be accessed at www.mandatedreporterca.com.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7
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
VISIT DATE: 08/30/2022
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
26
27
28
29
30
31
32
Licensee and assistant CPR/First-Aid expires on May 18, 2023 and Licensee Victor Gomez CPR/First-Aid expires on May 18, 2024. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee, Lourdes Gomez, and assistant's immunizations are on file. Licensee, Victor Gomez, is missing immunizations.

Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Lourdes Gomez.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPAs Teodoro Trujillo and Susy Cervantes informed licensee Lourdes Gomez that this report dated August 30, 2022 document(s) one (1) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA LPAs Teodoro Trujillo and Susie Cervantes informed the licensee Lourdes Gomez to provide a copy of this licensing report dated August 30, 2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYSFailure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7