444409933-9-10-2021-07-CC-CNEN-C6QV7G-20210910161106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444409933
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:11:12 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, LUCIA		FACILITY NUMBER:	444409933
ADMINISTRATOR:	LUCIA GOMEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 763-0672
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	14	CENSUS: 9	DATE:	09/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lucia Gomez		TIME COMPLETED:	04:20 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	#2 Licensing Program Analysts (LPAs) Cortney Nelson and Marilou Monico conducted an unannounced Required - 1 Year inspection. LPAs met with Licensee, Lucia Gomez, and explained the purpose of today's visit. Also present in the home were Licensee's two adult sons, Licensee's son's girlfriend, eight daycare children, and Licensee's eight-year-old daughter. There are four adults residing in the home: Licensee, Licensee's husband, and Licensee's two adult sons. Additionally residing in the home is Licensee's minor daughter. The daycare is open Monday thru Friday from 6:00 AM to 6:00 PM. The indoor and outdoor areas were inspected. There is a 3A40BC fire extinguisher present. There were no bodies of water observed. Off limit areas in the home: garage, two bedrooms, master bedroom, and master bathroom. Off limit areas outside the home: half of the backyard and the entire side yard. Cleaning compounds, sharp objects, and other similar items were stored inaccessible to children. Licensee maintains a current children's roster. The last fire/disaster drill was conducted on September 7th, 2021. Per licensee, there are no weapons in the home. Eight children's files were reviewed. Licensee and her son, Fabian, have current Pediatric CPR/First Aid certifications. LPAs obtained a copy of children's roster during the inspection. LPAs discussed Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee's Mandated Reporter Training expires on February 3, 2022. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Continuation on next page:

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2150
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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, LUCIA	FACILITY NUMBER: 444409933
	VISIT DATE: 09/10/2021

NARRATIVE

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LPAs reviewed with Lucia and provided her a copy of Safe Sleep Regulations (PIN 20-24-CCP).

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Incidental Medical Services (IMS) was discussed. Licensee stated that she's not planning to provide IMS at this time

Licensee was requested to update and submit the following by 9/30/2021:
1. Application for a Family Child Care Home License (LIC279)
2. Facility Sketch (LIC999) for Yard
3. Current Children in your Home (LIC279B)

As a result of this inspection, no deficiencies were cited:

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

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2150
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

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