434414129-11-8-2019-07-CC-DMAC-BHQVMW-20191108153413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414129
Report Date: 11/08/2019
Date Signed: 11/08/2019 03:34:21 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, CLARIBEL		FACILITY NUMBER:	434414129
ADMINISTRATOR:	GOMEZ, CLARIBEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 420-8552
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	14	CENSUS: 6	DATE:	11/08/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Claribel Gomez		TIME COMPLETED:	03:40 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) Dung Mac met with Claribel Gomez, Licensee, for an unannounced annual inspection. LPA observed an adult female, Licensee's sons age 2 and 12, Licensee's two-month twins, Licensee's daughter age 8, and three preschool children in the home during today's inspection. Days and hours of operation are: Monday-Friday 6:00am-6:00pm. LPA toured the home both inside and out. Off-limit areas are all bedrooms and garage. Fireplace is covered. Backyard is fenced all around and the storage shed is locked. LPA did not observe any bodies of water. Licensee states that there are no firearms in the home. Detergents, cleaning products, medications, hazardous and other toxic materials are inaccessible to children. Medications is stored in upper kitchen cabinet. LPA observed a fully charged 2A10BC fire extinguisher. Smoke and Carbon Monoxide detectors were tested and proved to be functioning. The home is clean, orderly, and safe for the day care children. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee stated that she does not transport children. The last fire/disaster drill was conducted on 9/12/19. LPA reviewed the Child Care Facility Roster. Three children's files were reviewed and all are complete. Continued on Page #2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

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, CLARIBEL	FACILITY NUMBER: 434414129
	VISIT DATE: 11/08/2019

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 26 27 28 29 30 31 32	Continued from Page #2 LPA provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep Information to Licensee. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing updates and regulations. No deficiencies was cited today. An exit interview was conducted. Notice of Site Visit was given to Licensee and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3

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, CLARIBEL	FACILITY NUMBER: 434414129
	VISIT DATE: 11/08/2019

NARRATIVE

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Continued from Page #1

Licensee, Licensee's spouse, and Assistant Martina Toro's files were reviewed and all maintain records of immunizations. Licensee's Pediatric CPR & First Aid certification expires on 8/15/20. Licensee's Mandated Reporter certificate expires on 1/06/20 . LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every two years.

Adults who reside in the home are Licensee and spouse. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks.

A review of staff records on 11/08/19 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 the 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.

Licensee stated she does not have any children in care who requires administration of medication. The facility is not providing Incidental Medical Services at this time. IMS was discussed. The following US Department of Justice resource was provided: http://www.ada.gov/childqanda.htm.

Continued on Page #3

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019

LIC809 (FAS) - (06/04)

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