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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008953
Report Date: 01/21/2022
Date Signed: 01/24/2022 08:45:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BRAMBILA GOMEZ, LAURA FCCHFACILITY NUMBER:
493008953
ADMINISTRATOR:BRAMBILA GOMEZ, LAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 837-8184
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:14CENSUS: 5DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Laura Brambila GomezTIME COMPLETED:
03:57 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. A review of staff records on 01/21/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index. clearances or exemptions. Licensee was reminded 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. There are currently three adults living in the home.

During today’s inspection the home and grounds were toured. The licensee was supervising five children. The facility’s operating hours are 07:30am to 04:30pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home were made inaccessible by door locks and/or child gates. The children have access to the home's living room, family room/ nap room, kitchen, and downstairs bathroom. The garage and all bedrooms and the second floor are off limits and inaccessible. The home was observed to be clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire in April 2022. The licensee's CA mandated reporter training certificate expires October 2023. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be stored out of the reach of children. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated that firearms, ammunition, and poisons are not stored on the premises. The children use the home’s backyard as the outdoor play area. It is fully fenced. There were no bodies of water located on the premises. Four children's records were reviewed during today's inspection. Children's immunization records, identification and emergency forms, and notification of parent's rights forms were on file. The licensee currently has infants under 24 months of age enrolled at the facility. The licensee did not have any completed 15 minute safe sleep check logs for the LPA to review. Continued on LIC 809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BRAMBILA GOMEZ, LAURA FCCH
FACILITY NUMBER: 493008953
VISIT DATE: 01/21/2022
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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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Other links to resources were provided as well.

Incidental Medical Services (IMS) policy was discussed. 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 (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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BRAMBILA GOMEZ, LAURA FCCH
FACILITY NUMBER: 493008953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's file review on 01/21/22 and the licensee's own admission, the licensee did not comply with the section cited above and provide proof that 15 minutes checks were being conducted during infant's nap time, which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee stated that no other records were available for review.
POC Due Date: 01/28/2022
Plan of Correction
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The licensee stated she would produce a written statement detailing how the facility intends to conduct 15 minute checks and how the facility intends to comply with the regulation cited above. LPA provided licensee with a copy of a sample infant sleep log. Furthermore, the licensee will also submit a completed 15 minute sleep check log for the LPA to review. The POC will be submitted to the Department by 01/28/22 via mail, email or fax.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2022
LIC809 (FAS) - (06/04)
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