434407067-12-31-2019-07-CC-SYIP-BKDSXG-20191231131556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407067
Report Date: 12/30/2019
Date Signed: 12/31/2019 01:16:01 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:	DOMINGUEZ, ANA		FACILITY NUMBER:	434407067
ADMINISTRATOR:	DOMINGUEZ, ANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 776-0050
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	14	CENSUS: 9	DATE:	12/30/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Ana "Mellie" Dominguez		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced annual random inspection. LPA met with Licensee Ana "Mellie" Dominguez and explained the reason for the inspection. Present during the inspection were Licensee, her mother, and 9 children. All adults present have fingerprint clearance. License, Emergency Disaster Plan, and Notification of Parent's Rights were observed to be posted. There is working phone in the home. The hours of operation are Monday through Friday 5:30AM to 6PM. LPA toured in the inside and outside of the home with Licensee. The off-limit area of the home are the entire upstairs, kitchen, office, and room downstairs. There is a door to barricade the upstairs. There is wall heater, which is barricaded. LPA reminded Licensee to ensure that barricaded is placed where it prevents access to children. All disinfectant, cleaning, supplies, and other items that are dangerous to children in care were inaccessible to children. LPA reminded Licensee that any disinfectant sprays, such Lysol, needs to be inaccessible to children and mop bucket is put away. LPA observed that there is sufficient amount of toys for children in care. Furniture and equipment, such as tables, chairs, and napping cots, were observed to be in good conditions. LPA observed a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 06/08/2019. LPA reminded Licensee that fire/disaster drill needs to be conducted every 6 months. Licensee stated that there are no weapons, such as firearms, stored in the home. Licensee uses the common outdoor area and her front patio. Licensee stated that they will close the gate leading to the parking lot when children are outside. LPA reminded ----------------------------continues on 809 dated 12/30/2019 page 2--------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2019

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: DOMINGUEZ, ANA	FACILITY NUMBER: 434407067
	VISIT DATE: 12/30/2019

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--------------------continuation of 809 dated 12/30/2019 page 1------------------------------------
Licensee to check outdoor area and front porch for anything that needs to be replaced, such as nails that might be protruding. There were no bodies of water observed during today's inspection.

LPA stated that she currently does not transport children at this time, but understands that children cannot be left alone and unattended in parked vehicles.

5 children's files were reviewed during today's inspection. The records reviewed include but not limited to consent for emergency medical treatment and parent's rights. LPA reminded Licensee to check that parent's sign all forms.

Licensee and her mother have a valid CPR/1st Aid, which expires on 01/02/2020. Licensee and her mother's immunization records are on file. LPA has completed the Mandated Reporter Training. LPA reminded Licensee that the Mandated Reporter training requires renewal every two (2) years. Licensee stated that her mother is waiting for the Spanish version to come.

The adults living in the home are Licensee and her son. All adults living in the home have cleared criminal record clearance and child abuse index clearance.

Licensee stated she currently does not have any children in care who requires incidental medical services. 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 and provided Licensee with Safe Sleep and Lead Exposure. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

In the areas evaluated during today's inspection, no deficiencies have been cited. An exit interview was conducted were this report was discussed and provided to Licensee Ana "Mellie" Dominguez. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2019

LIC809 (FAS) - (06/04)

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