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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406226
Report Date: 06/11/2019
Date Signed: 06/11/2019 03:50:49 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, EVA & MURILLO, JUANFACILITY NUMBER:
444406226
ADMINISTRATOR:GOMEZ, EVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 761-1479
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:14CENSUS: 7DATE:
06/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Eva GovezTIME COMPLETED:
04:05 PM
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Unannounced random visit made by Mahvash Behbood. Met licensee, purpose of the visit explained. Present also were the Co-Licensee/helper and 7 day care children, all over 2 years old. Days and hours of operation is M through F from 6 AM to 6 PM. Inside and outside of the home inspected. children and staff file reviewed.
There are no bodies of water on the property.
Licensee stated there are no gun at home.
Cleaning supplies stored inaccessible to children.
No fire place in day care area. Fire extinguisher is the correct size. Smoke and carbon monoxide are operational. Licensee states the heater works properly. No stairs
Toys and play equipment are safe and age appropriate.
Telephone is working and the phone number is still the same.
Children were supervised during the visit.
Discussed with licensee children are not to be left in parked vehicles.
Backyard where children play is fenced.
Licensee's roster was up to date. There is an emergency information on file for all children in care.
The adults who live in the home are licensee, her husband, her 13 year old daughter, and her adult son. All adults have obtained finger print clearance. A renter lives on the property who has finger print clearance
CPR and First Aid is expired on 01/17/2020 . Staff are current with their immunization records. Both licensee have completed the mandated Child Abuse Reporter Training.
IMS is not being provided.
Off limits: Garage, all bedrooms, living room, the second bathroom. Outside: 2 sheds and both side yards.
No deficiency noted during today's visit
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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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