444406009-4-24-2023-07-CC-EBEN-CR7Q2E-20230424114658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444406009
Report Date: 04/21/2023
Date Signed: 04/24/2023 11:47:40 AM

Document Has Been Signed on 04/24/2023 11:47 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, ALFONSO		FACILITY NUMBER:	444406009
ADMINISTRATOR:	GOMEZ, ALFONSO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 724-2361
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	14	CENSUS: 1	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Alfonso Gomez		TIME COMPLETED:	01:30 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), Elizabeth Berumen conducted a Required - 1 Year Inspection. LPA met with Licensee, Alfonso Gomez, and explained to her the nature of today's inspection. Also present in the home were Licensee's wife, Aurelia Gomez, his adult daughter, Jacqueline Gomez and 1 week old granddaughter. No day care children were present. The day-care is open Monday thru Friday from 6:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. 4Licensee states there are three adults living in the home; himself, his wife and daughter (Jacqueline Gomez). Licensee states that he has a new born granddaughter that lives in the home. LPA took a picture of current children's roster (LIC9040). Fire/disaster drill was conducted on November 1, 2022. LPA reminded Licensee that he is to document the date including month, day and year. Currently Licensee is just writing the month. LPA observed a fully charged 3A40BC fire extinguisher which was serviced on April 3, 2023. Fire place in living room is barricaded. Licensee states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. Licensee states that he is not planning to administer any medication at this time. 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 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 LPA reminded licensee that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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. Continuation on next page:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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, ALFONSO	FACILITY NUMBER: 444406009
	VISIT DATE: 04/21/2023

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

Off limit areas in the home include: 3 bedrooms, bathroom 2 and detached garage. Side yards are off limits. No bodies of water were observed. LPA requested Licensee to update the facility sketch and include the detached garage.

LPA reminded Licensee that sharp objects, and other items that are dangerous to children are to be stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The home has a working telephone which is (831)724-2361.
LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended she registers all infant devices with the CPSC to be notified of any recalls on her purchased equipment.

LPA reviewed two children’s files for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Immunization Records, and Notification of Additional Children in Care (LIC 9150). Child's file is missing the affidavit regarding liability insurance. LPA reviewed Licensee's file: Licensee is missing the mandated reporter training. Immunization for measles and pertussis was not available for review. Today, Licensee, Alfonso Gomez signed a statement indicating that for health reasons he does not take the influenza vaccine.
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/process

Exit interview conducted and report was reviewed in Spanish with Licensee, Alfonso Gomez.

As a result of today's inspection, deficiencies were cited on the following pages:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/24/2023 11:47 AM - 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, ALFONSO	FACILITY NUMBER: 444406009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. Licensee does not have the mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete the general training and child care provider training at mandatedreporterca.com by plan of correction date of April 28, 2023 and send a copy to CCL.

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. Licensee did not have proof of immunization against pertussis and measles which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit copy of immunization against pertussis and measles by plan of correction date of May 5, 2023.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 04/24/2023 11:47 AM - 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, ALFONSO	FACILITY NUMBER: 444406009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 1 is missing the affadavit regarding liability insurance which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of signed affadavit LIC282 to CCL by plan of correction date of April 28, 2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4