434410646-10-21-2021-07-CC-PHEZ-C7ZRBJ-20211021125249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410646
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:53:34 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, 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: 3	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alexandra Gomez Padilla		TIME COMPLETED:	01:10 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	Licensing Program Analyst (LPA) Pete Hernandez Required unannounced Required 1 Year inspection at the home today. LPA met with Licensee, Met with Daughter Alexandria Gomez Padilla and her husband Modesto Gomez-Lopez.. Licensee is renting her six bedroom house. She resides in the house with her husband and three adult children: Alexandria, Elizabeth and Sasha. There was 3 day care child present at the time of LPAs arrival: 2 preschoolers and 1 infant. 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 and three adult Daughters. 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 5/11/2021. 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, back yard, and garage. LPAs observed 1 fully charged 2A10BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home. 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 locked up or are inaccessible to children. *LPAs reviewed the files of 5 enrolled children and 3 Staff. All documentation and immunizations were complete.* REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 10/21/2021:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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: 10/21/2021

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed with Licensee. Licensee does not currently provide IMS services. 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 the form LIC9227 as it related to infants.

Licensee and her husband both have current PR and First Aid cards. Maria's expires on 6//6/2023 and her Husband Mordeso's expires on 7/17/2023.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 10/21/2021:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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: 10/21/2021

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Licensee, and husband and Daughters have copies of mandated reporter training certificates at the day care during inspection. Licensee's certificate is scheduled to expire 2/8/2022 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

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

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22 An exit interview was conducted was reviewed with the licensee. A copy of this report was discussed and left with the Licensee, Alexandra Gomez, whose signature on this form confirm receipt of these documents.

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: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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