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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414129
Report Date: 12/22/2022
Date Signed: 12/22/2022 10:29:01 AM


Document Has Been Signed on 12/22/2022 10:29 AM - 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, CLARIBELFACILITY NUMBER:
434414129
ADMINISTRATOR:GOMEZ, CLARIBELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 420-8552
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 6DATE:
12/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Gomez, ClaribelTIME COMPLETED:
10:40 AM
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On this day Licensing Program Analyst/s (LPA/s) Almaraz conducted a follow up inspection, of a large family childcare home (capacity of 14). The previous visit was conducted 12/20/2022. 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. Present during the inspection were licensee with six children, three preschoolers and three school age, including three of the licensee’s children. In the previous inspection the licensee was cited for the following deficiencies: 1. Operation of a Family Child Care Home 102417 (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. 2. Criminal Record Clearance 102370 (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.

LPA observed licensee provided a copy of licensing report dated 12/20/2022 that documents the Type A citation(s) to parents/guardians of all children currently enrolled. Licensee provided a signed Acknowledgement of Receipt of Licensing Report (LIC 9224), all signed 12/20/2022 or other written statement, placed in the child's file for verification.

LPA observed the during this visit: 1. Supervision of the children in care. 2. All adults present had a fingerprint clearance. 3. Personal rights accorded. 4. Ratio requirements met. 5. Capacity requirements met. On 12/20/2022, LPA obtained two written declarations, (LIC 855) for each violation as part of the plan of correction. Finger print clearances have been submitted, obtained and cleared for Staff 1 as part of the plan of correction. LPA and licensee discussed the personnel requirements for staff, including immunization's and Mandated Reporter Training requirements. These citations have been cleared, a POC letter was provided to licensee during visit. No further follow up needed at this time. There are NO deficiencies issued in accordance with Chapter 1, Division 12, Title 22 of the California Code of Regulations. An exit interview conducted, and report was reviewed with licensee.

NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS. 1/1

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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