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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405947
Report Date: 09/09/2019
Date Signed: 09/09/2019 02:52:49 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, MARICELAFACILITY NUMBER:
434405947
ADMINISTRATOR:GOMEZ, MARICELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 269-8711
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 9DATE:
09/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maricela GomezTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA), Stephanie Rangel, conducted an annual random inspection. LPA met with licensee, Maricela Gomez. There were 3 adults and 9 children present (1 infant and 8 preschool age). Days and hours of operation are Monday thru Friday from 6:30 AM to 6:00 PM. There are 4 adults residing in the home: licensee, her husband, and two daughters. Licensee carries day care insurance.
LPA reviewed 5 children's files which contain the Identification and Emergency Information form (LIC 700). LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the daycare children. The home is clean, orderly, and safe for the daycare children. LPA observed a barricaded fireplace inside the home. Off limit areas in the home: garage and the entire second floor including 4 bedrooms & 2 bathrooms. The stairs have been barricaded from the bottom. Off limit areas outside the home: locked backyard shed and gated right side yard. LPA observed a fenced backyard, fully charged 3A40BC fire extinguisher, functioning carbon monoxide detector, and working smoke detector. LPA observed no bodies of water. Licensee states that there are no weapons in the home. Cleaning products, sharp objects, and other similar items are stored inaccessible to children. LPA observed a current fire drill log (last conducted 7/29/19) and current CPR/1st Aid certifications for Licensee that expire 3/2020.
Incidental Medical Services (IMS) policy was discussed. Licensee does not have any children that require IMS. A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Effect of Lead Exposure handout dated 1/20/19 given during today’s inspection. Licensee understands that per Assembly Bill (AB 2370), written information regarding lead exposure needs to be given out to enrolling and re-enrolling parents or guardians.

As a result of this inspection, no deficiencies were cited. NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2019
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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