434410646-10-23-2019-07-CC-PHEZ-BH8NMR-20191023103534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410646
Report Date: 10/23/2019
Date Signed: 10/23/2019 10:35:45 AM

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, MARIA		FACILITY NUMBER:	434410646
ADMINISTRATOR:	GOMEZ, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 687-1401
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY:	14	CENSUS: 1	DATE:	10/23/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Maria Gomez		TIME COMPLETED:	10:40 AM

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) Pete Hernandez , (LPA) Tuoc Doan conducted an unannounced annual inspection at the home today. LPA met with Licensee, Met with Maria Gomez and her husband Modesto Gomez-Lopez.. Maria is renting her six bedroom house . She resides in the house with her husband. There was 1 day care child present at the time of LPA’s arrival. Hours are Monday - Friday from 6:30 PM to 6:30 PM. The adults that reside in the home are the Licensee and her Husband. Licensee Maria Gomez also holds a Foster Care License #0F40092. LPAs toured the indoor or and outdoor areas of the home. Licensee maintains a current child roster. Fire drills are conducted every 6 months and logged: last log was 9/18/19. The Licensee has a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children. Off limit areas are: upstairs, Maria's room and garage. LPAs observed 1 fully charged 2A10BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home. Licensee says they are installing a new carbon monoxide detector today. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, other similar items and poisons are in the garage and are inaccessible to children. *LPAs reviewed the files of 6 enrolled children. All documentation and immunizations were complete.* REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 10/23/2019:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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, MARIA	FACILITY NUMBER: 434410646
	VISIT DATE: 10/23/2019

NARRATIVE

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Licensee, husband, and helpers have copies of mandated reporter training certificates at the day care during inspection. Licensee's certificate is scheduled to expire 11/3/2019 and is aware that she needs to take the training every 2 years. LPA advised Licensee of the Mandated Reporter Training per AB1207 for Child Care Providers to be accessed at www.mandatedreporterca.com

CPR and First Aid cards were all current. Licensee's and her husbands are set to expire on 6/15/2021.

Licensee and husband have current immunizations .

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPAs also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

There were no Title 22 violations cited during this inspection.

LPAs conducted an exit interview with the Licensee .

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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, MARIA	FACILITY NUMBER: 434410646
	VISIT DATE: 10/23/2019

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed with Licensee. Per Licensee, she currently does not have any children in care who requires IMS. 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

A review of staff records today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period

Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.

LPA informed Licensee that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

LPA discussed with and provided Lead Safety Information (AB2370) to the Licensee.

LPA discussed and provided Safe Sleep Child Care information to the Licensee.

LPA discussed and provided Healthy Beverages in Child Care information (AB2084) to Licensee.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 10/23/19:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC809 (FAS) - (06/04)

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