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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413417
Report Date: 05/21/2019
Date Signed: 05/21/2019 10:06:57 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, PATRICIAFACILITY NUMBER:
434413417
ADMINISTRATOR:GOMEZ, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 937-6264
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:14CENSUS: 2DATE:
05/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Patricia GomezTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual Inspection of the Family Day Care home. LPA met with Licensee Patricia Gomez and explained the purpose of the inspection. Present during the inspection were two children in care, of whom one was infant age. Licensee stated that she understands her capacity options and she understands that when she has more than 12 and up to 14 children, one child has to be attending school and one child has to be at least 6 years old. Licensee also stated that she understands that she must comply with the ratio and capacity requirements of a small Family Child Care Home license whenever there is only one person providing care and supervision to the children at the home.

Days and hours of operation are Monday through Friday from 6:00 AM to 5:30 PM. The home maintains telephone service. The License and Notification of Parents’ Rights were observed to be posted.

The home was inspected inside and out. The home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. LPA did not observe flies, other insects, and rodents during the inspection. The observed children’s toys, play equipment and materials were in good condition. Furniture and equipment, such tables, chairs, mats, cots, play pens, etc. were age appropriate and in good condition. There were no baby walkers observed to be in used. Bathroom used by children was observed to be sanitary and in operating condition. Food preparation area was clean.

Off limit areas in the home are: the whole second floor, all three bedrooms and master bathroom on the first floor, and the Laundry room. There is a child safety gate installed at the base of the stair case to prevent children from accessing the stairs to the second floor. The backyard is fenced but per Licensee is not currently used by children for outdoor activity. There were no bodies of water observed. Licensee stated that there were no weapons stored on the premises during Day Care hour. Licensee stated that when firearm is present in the home, there are two locked safe to store the firearm and ammunition separately.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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, PATRICIA
FACILITY NUMBER: 434413417
VISIT DATE: 05/21/2019
NARRATIVE
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A fully charged fire extinguisher was observed. Carbon monoxide and Smoke Detectors were tested and proved to be functioning. Log shows that Fire and Disaster drill was last conducted on 02/15/19. Licensee stated that she does not transport children at this time but she understands that children could not be left unattended in parked vehicles at any time.

Facility has two Labrador dogs that are kept in the backyard. Per Licensee, the dogs are up to date with immunization/registration and are kept inaccessible to day care children.

LPA reviewed the roster of children in care and obtained a copy. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Medical Treatment, Receipt for Parents' Rights Notice, and Immunization. Licensee and the Assistant Providers' files were reviewed. Records reviewed include Criminal Record and Child Abuse Index Background Check Clearance, TB clearance, Statement Acknowledging Requirement to Report Suspected Child Abuse, Immunization record for Measles and Pertussis, and required Training. Licensee Pediatric CPR and First Aid certification expires October 2019 and AB1207 Mandated Reporter certification expires on 06/12/2020.

Adults who are over the age of 18 and reside in the home are Licensee, and Licensee's Spouse, two Sons and Daughter. They have Clearance for Criminal Record and Child Abuse Index Background Check, and Tuberculosis. LPA 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. LPA also reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Safe sleep information was reviewed with Licensee. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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, PATRICIA
FACILITY NUMBER: 434413417
VISIT DATE: 05/21/2019
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes 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.

In the areas that were evaluated, a regulatory violation was observed at the time of the inspection; therefore, a citation was issued. Exit Interview was conducted, where this report, the Citation, Plan of Corrections, and Appeal Rights were reviewed and discussed with Licensee

A copy of this report was provided to facility at the conclusion of the site inspection.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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, PATRICIA
FACILITY NUMBER: 434413417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2019
Section Cited
HSC
1597.622
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HEALTH & SAFETY CODE. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. [...] The family day care home shall maintain documentation of the required immunizations.
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BY POC DUE DATE, 06/04/19, Licensee agreed to obtain a copy of Licensee's documented proof of immunity against Measles and Pertussis.

A copy of the document will be sent to Licensing Office to show proof of correction.
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This requirement is not met as evidenced by:
Based on LPA's review of file, Licensee does not have documented proof of immunity against Measles and Pertussis. This poses a potential risk to the health and safety of children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4