434414129-12-20-2022-07-CC-AALZ-CMAUZ8-20221220150108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414129
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:02:18 PM

Document Has Been Signed on 12/20/2022 03:02 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:	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: 7	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Gomez, Claribel		TIME COMPLETED:	03:30 PM

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On this day Licensing Program Analyst/s (LPA/s) Almaraz conducted an unannounced annual inspection, of a large family childcare home (capacity of 14). Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA/s met with licensee Gomez, Claribel.

There were seven children present during the inspection, including four preschoolers and three school age, including three of the licensee’s children. The hours of operation are 5:00 AM to 6:00 PM, Monday to Friday. There are 2 adults residing in the home, licensee and spouse Ortiz, Francisco and five minor children. At the start of the inspection, LPA was greeted by minor child and told to wait for licensee. Approximately 5 minutes later licensee arrived at the facility. The children were with staff # 1, (S1) an uncleared adult assistant in the home. Per licensee this is a volunteer, the regular assistant Toro, Martina had to leave the area due to a family emergency.

Physical Plant: This is a single-story dwelling which consists of 3 bedrooms and two lavatories. LPA/s inspected the indoor and outdoor areas of the home today. Per licensee Off limit areas in the home are as follows: 1. All bedrooms, made inaccessible by a lock. 2. One bathroom. 3. A separate converted garage.

Off limit areas outside the home are as follows: The side yards both gated, one sheds, locked. The backyard is fully fenced. The front yard is safety complaint. The children use the back yard for outdoor activities. LPA discussed ensuring the fence remains safety compliant, there is wear and tear on the back left fence, this is currently not a safety risk.

During this inspection, the following was noted: At 11:30 AM, LPA/s began tour through the interior of the home. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating for safety and comfort. Per licensee there are no pets.

Kitchen: All kitchen areas/food preparation and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. LPA checked that water and refrigerator temperatures in standard condition. Per licensee waste is discarded immediately after each meal. 1/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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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Document Has Been Signed on 12/20/2022 03:02 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: GOMEZ, CLARIBEL	FACILITY NUMBER: 434414129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(a)

Operation of A Family Child Care Home

(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above, as evidenced by the children were alone in care of an uncleared adult assistant and the licensee was not present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2022
	Plan of Correction
1 2 3 4	Licensee must submit an LIC 855 on or by 12/21/2022 that the above regulation is understood and explain how this requirement will be adhered to moving forward.

Type A

Section Cited

CCR

102370(d)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above, LPA observed a non fingerprint cleared adult assistant with the children in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2022
	Plan of Correction
1 2 3 4	Licensee would like S1 to continue to volunteer if needed. Licensee must submit proof of fingerprint clearance to LPA on or by 12/21/2022; or a statement that S1 will not volunteer in facility. Licensee must submit a statement LIC 855 that the above regulation is understood and that S1 will not return to the facility during day care hours until first finger print cleared. Licensee must include a plan in the event of an emergancy.

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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: GOMEZ, CLARIBEL	FACILITY NUMBER: 434414129
	VISIT DATE: 12/20/2022

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Food: Per licensee meals are prepared at the facility daily. Licensee provides breakfast, lunch and AM/PM snacks. LPA and licensee discussed that food brought from home must be labeled. Per licensee there are no children enrolled with allergies. LPA has advised licensee to keep an allergy list in the kitchen area, should there be any children enrolled with allergies. LPA and licensee discussed having the 5 food components kept on site.

All areas identified on the facility sketch were inspected. Areas that are accessible to day-care children are the living room, dining room, kitchen and one lavatory.

The licensee understands that areas that are off-limits must remain inaccessible to the children in care during operating hours. The licensee does understand that licensing staff may have access to off-limit areas during an inspection visit if necessary.

Lavatories: There is one lavatory that is accessible to the children in care. There is a change table with an appropriate change pad. Licensee states that potty training is provided at facility.

Outdoor play: The fully fenced back yard has adequate shade in the play yard.

Hazards: LPA did not observe any hazards inside the home. There is one electrical outlet that LPA advised shall be covered. Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children was observed out of reach or locked from the children in care. The licensee states that there are no poisons in the home, they are kept in a locked shed in the backyard. The licensee was advised that all poisons must be locked with a key or combination lock. LPA also observed appropriate equipment, toys, and games for children. Per licensee there are no firearms in the home. There were no bodies of water observed to be inside or outside of the home.

Fire & Safety: Carbon monoxide detectors and smoke detectors are working and present in the facility. There is a fully charged fire extinguisher, size 3A40BC, Last fire drill 07/08/2022, licensee understands a fire drill is to be completed at least every six months. A fireplace covered by furniture observed to be in the home. There are wall heaters observed to be on the ceiling, out of reach. Per licensee there is no smoking in the home.

Facility Records: The licensee has CPR and First Aid, valid until 08/13/2024. Licensee has record of MMR & Tdap vaccinations, opt out of flu vaccine. Licensee, spouse, have record of TB tests. Licensee has completed the Mandated Reporter Training valid until 08/23/2024. The licensee understands this must be renewed every two years. LPA/s discussed the form requirements for staff and children's files. LPA issued an LIC 857 and 859, review of children and staff files. 2/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 3 of 8

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: 12/20/2022

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Sign in and out: Per licensee there is a monthly sign in/sign out system. LPA informed licensee that this is not mandatory for a FCCH.

Waivers: There are no waivers or requests on file.

Medical & First Aid Supplies: There is a first aid kit in the home, kept in the children’s outside area. LPA and licensee discussed that medication is only to be administered to a child when accompanied with a doctor's note, parent plan, authorizations are to be completed monthly. The medication shall be kept in a locked cabinet or in a locked box in refrigerator if needed and/or in emergency backpack when children outside (at least six feet high) which is stored out of reach of children. LPA and licensee discussed that medication, and first aid supplies shall be accessible to staff at all times during care.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Matts and cots: Per licensee napping is done at this facility. LPA observed matts for napping in a safe condition with no exposed foam. Constructed of material at least 3/4 inch thick. Covered with vinyl or similar material that can be wiped. Designed so that the sleeping side can be distinguished from the floor side. Per licensee cots are wiped weekly with a detergent, disinfectant or when soiled or wet. Each matt observed to be equipped with a sheet and/or blanket to cover the child. Per licensee bedding is not shared. Per licensee sheets/blankets shall be when soiled. LPA advised that bedding shall be individually stored so that each child's bedding is identifiable, and no child's used bedding shall meet other bedding. Bedding is washed at facility weekly (Fridays).

Safe sleep: LPA/s advised that sleeping equipment for infants shall be safety compliant. LPA/s advised cribs for each infant who is unable to climb out of the play yard. Equipment must the US Consumer Product Safety Commission safety standards. Please see www.safekid.org for a list of any recalled products. LPA/s advised that cribs must be free from loose articles and objects. No objects hanging above or attached to the side of the cribs. LPA reminded licensee that play yards shall not hinder the entrance or exit to and from the space children are sleeping in. 3/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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: GOMEZ, CLARIBEL	FACILITY NUMBER: 434414129
	VISIT DATE: 12/20/2022

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LPA discussed with licensee the following: Each infant must have their individual bedding and is to be washed daily or as required. Bedding must be replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers must not be attached to anything. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping. LIC 9227 (Individual Sleeping Plan) for infants up to 12 months was discussed. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the licensee, including but not limited to documentation that shall be maintained. A review of PIN 20-24-CCP Recently approved Safe Sleep Regulations in Effect was discuss and a copy was provided to the Licensee during this inspection. LPA advised that a sleep log shall be kept for infants in care. Licensee must physically checks on infants at least every 15 minutes and documents the following: 1. Breathing, Sleep position, signs of distress. There were no infants observed to be in care. Per licensee there are no infants in care under 12 months old. There is one infant that is one years old, there is one folding crib that is put away when infant is not in care.

LPA advised licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. For commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Postings: LPA observed the required postings, including, Parent’s Rights Poster (with complaint Hotline), an emergency disaster plan, the license and any notice of site visits.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Licensee was reminded that all adults 18 and over, 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 Child Care Center. 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. LPA observed that upon inspection there was a non-fingerprint cleared adult alone with the children in care. 4/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: 12/20/2022

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SB792 (Immunization Requirements for Staff and Employees) was discussed with the facility representative.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

The following was discussed with the licensee:

-Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalty will be assessed if not in compliance.

-In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated with the facility license.

-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

-Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated.

-The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes, and/or if you move from your home.

-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624B for written report).

-Fire and safety drills must be performed every six months and documented for review by the Department.

-Smoking is prohibited in a family childcare home.

-Children and Staff records must be maintained and updated as needed and must be available for review by the Department. 5/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: 12/20/2022

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- No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines, and any other item that falls into that category are not permitted in the facility.

-All adults living and working in the home shall be made aware of the Department's right to inspection authority, which includes but is not limited to the right to enter the home when children are being cared for, interview children and adults, and review documentation.

- Licensees shall reveal each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

- Emergency Disaster Plan, Parent’s Rights Poster, and the Facility License are required to be posted.

Per licensee, there is no liability insurance or a bond in accordance with the standard established by the Family Child Care statute. The law requires a Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file. Signed statements (LIC282) noted on children’s files. LPA and licensee discussed that the home insurance may cover this. There is transporting of children, licensee understands safety requirements.

LPA consulted and explained Child Abuse Reporting, Effects of Lead Exposure Flyer, Updated Patent’s Rights Poster with Complaint Hotline information, Capacity Handout (Small & Large) was provided during this inspection. LPA advised the applicant how to access forms, regulations and quarterly updates, and Provider Information Notices (PIN) on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the information on /Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms: Children forms/records, Facility forms/records, facility forms/ records, and Information to be posted in the Family Child Care Home.

During this inspection, Licensing staff consulted with licensee regarding COVID-19 health and safety guidelines on this date, licensee was provided CCP- COVID 19 Self- Assessment and forms to post. Per licensee, the following safety precautionary measures will be taken during the pickup and drop off of children: Daily health checks and screening upon entry will be conducted by Licensee.

The following was discussed: 1. Maintain an allergy list. 2. In the event that a fingerprint cleared visitor would like to volunteer at the facility, a file must be maintained. 3. The importance of finger print clearances. 4. Supervision. 5. The requirements of infants under and over 12 months old. 6. To maintain the back yard fencing and check for wear and tear, LPA observed back left to show early signs of wear and tear. 7. The children that live in the home shall have physical files. 8. To have a system to keep children's blankets separate. 6/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: 12/20/2022

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LPA Almaraz informed licensee Gomez, Claribel that this report dated 12/20/2022 document(s) two type A citations. Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Almaraz informed the licensee Gomez, Claribel to provide a copy of this licensing report dated 12/20/2022 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.

An exit interview conducted, and report was reviewed with licensee.

NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS. 7/7

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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