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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407067
Report Date: 03/04/2022
Date Signed: 03/04/2022 04:48:18 PM


Document Has Been Signed on 03/04/2022 04:48 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:DOMINGUEZ, ANAFACILITY NUMBER:
434407067
ADMINISTRATOR:DOMINGUEZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 776-0050
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:14CENSUS: 9DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Ashley Santos and Christopher PerezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Assistant Ashley Santos and explained the reason for the inspection. Ashley informed LPA that Licensee is currently not here due to needing to help a friend. Licensee's son, Christopher Perez arrived shortly after. Present during today's inspection were four Assistant and 9 children, whom 2 were infant age. Based on facility roster dated 03/01/2022 and record review, A-1 does not have cleared fingerprints and not associated to facility. LPA explained that A-1 cannot be present at the facility until her fingerprints are cleared and associated. Christopher and A-1 stated that they understood. A-1 left during inspection.

There is board to post required postings, such as license, parent's rights, and facility sketch. Licensee does carry daycare insurance.

LPA toured in the inside and outside of the home. The off-limit areas of the home are kitchen, office, storage room, and the entire upstairs. The door leading to the second floor was closed. Upon arrival, LPA observed that the door to the kitchen was open. There were cleaning supplies under the sink and knives the drawer. Children were napping upon arrival of inspection. Assistant did close the door to the kitchen. LPA reminded Christopher the door to the kitchen needs to be closed and any cleaning supplies or items that stated to keep out of reach of children needs to be inaccessible. There is open heater that is barricaded. LPA reminded Christopher to move barrier further so children do not have access to it. There were no baby walkers observed during today's inspection. There are

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 03/04/2022
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toys and equipment for children. Upon arrival, LPA observed that there was an infant who under 12 months sleeping in a play yard. The play yard had a play mat inside and a blanket that was laid on the bottom of the play yard for the infant to nap. LPA informed Ashley that there cannot be anything in the play yard when the infant is sleeping and there needs to be tight-fitted sheet. Ashley removed play mat and tucked the blanket in so it was tight fitted.
There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 02/15/2022. Christopher stated that there are no weapons, such as firearms, stored in the home.

The patio area is used and is fenced. LPA observed that the fence is starting to lean outward causing there to be a gap between the patio and the fence, which could become a safety issue with the children. Christopher stated that they will inform their building maintenance regards the fence. Christopher also stated that the daycare sometimes uses the play structure in the backyard, but due to construction that they do not use it all the time. LPA observed that there were some puddles on equipment. LPA reminded Christopher to make sure anything that collects water is dumped out.

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 does not provide Incidental Medical Services (IMS). Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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: 03/04/2022
NARRATIVE
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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

8 children's files were reviewed during today's inspection. The records reviewed include but not limited to Notification of Parent's right. C-1 did not have LIC 9227 on file. LPA observed that there was a sleeping log on file for C-1 dated 10/2021. Christopher stated that the sleep check was not completed today for both infants. C-2 only had immunization records, but was missing all other forms. Christopher stated that they will have parents fill out the forms and send proof to Licensing.

4 Assistant files were reviewed during today's inspection. The records reviewed include but not limited to immunization records and Mandated Reporter training. LPA observed that immunization records are on file for all assistants. All assistants did not have other required forms, such as LIC 508, LIC 9108, LIC 9052, and Mandated Reporter training on file. Christopher stated that they will have all assistant fill out all the forms and complete Mandated Reporter training. Christopher stated that they will send proof to Licensing. LPA also discussed with Christopher that TB test needs to be within 1 year of hire date. A-2 has a CPR/1st Aid, which expires on 01/31/2024. CPR/1st Aid was completed through American Health Care Academy and does not have a EMSA. LPA explained that any CPR/1st Aid that is not completed to American Heart Association or American Red Cross needs to be EMSA approved.

The adults living in the home over 18 years old are Licensee and her son. All adults have cleared criminal record and child abuse index. A copy of LIC 508 was obtained for her son during today's inspection. Christopher stated that he will submit a copy of his TB test.

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 15
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: 03/04/2022
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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.

Due to Licensee not being present during today's inspection, LPA was unable to conduct staff interview. LPA informed Christopher that annual inspection will continue and be completed on a later date.

As a result of this inspection, Type A, Type B, technical violations, and technical assistants were issued. A civil penalty of $500 was assessed for caregiver background check. Exit interview was conducted and report was reviewed with Licensee's son, Christopher Perez. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Samantha informed Christopher Perez that this report dated 03/04/2022 document 1 Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed Christopher Perez to provide a copy of this licensing report dated 03/04/2022 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.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 03/04/2022 04:48 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: DOMINGUEZ, ANA
FACILITY NUMBER: 434407067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. A-1 was present, but does not have cleared fingerprints and not associated to facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
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A-1 left during today's inspection and understands that she cannot work until her fingerprints are cleared and associated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 5 of 15


Document Has Been Signed on 03/04/2022 04:48 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: DOMINGUEZ, ANA
FACILITY NUMBER: 434407067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed that the kitchen door was open, which has cleaning supplies and knives. Assistant closed the door during today's inspection. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Deficiency was corrected during today's inspection.
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
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Based on record review, the licensee did not comply with the section cited above. All assistant have not completed the Mandated Reporter Training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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By POC 04/22/2022, all assistants will complete Mandated Reporter training and send proof to Licensing.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 6 of 15


Document Has Been Signed on 03/04/2022 04:48 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: DOMINGUEZ, ANA
FACILITY NUMBER: 434407067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 Assistants did not have forms filled out and in file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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By 03/18/2022, all assistants will have form filled out and send proof to Licensing.
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 assistants. All assistants did not have form filled out, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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By POC 03/18/2022, all assistants will have forms filled and send proof to Licensing.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 7 of 15


Document Has Been Signed on 03/04/2022 04:48 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: DOMINGUEZ, ANA
FACILITY NUMBER: 434407067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

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
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3
4
Based on record, the licensee did not comply with the section cited above. C-1 did not have forms filled and in file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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2
3
4
By POC 03/18/2022, Licensee will send proof of completed form to Licensing.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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