543904576-1-25-2022-04-CC-PESA-CAZS9B-20220125124028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 543904576
Report Date: 01/25/2022
Date Signed: 01/25/2022 12:40:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GAMBOA, ELVIRA FAMILY CHILD CARE		FACILITY NUMBER:	543904576
ADMINISTRATOR:	GAMBOA, ELVIRA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 781-0971
CITY:	PORTERVILLE	STATE: CA	ZIP CODE:	93257
CAPACITY:	14	CENSUS: 8	DATE:	01/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Elvira Gamboa, Licensee		TIME COMPLETED:	01:00 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	On 01/25/2022, Licensing Program Analyst (LPA), Pete Espinoza, conducted an unannounced Required 1-Year Inspection. LPA was greeted by Elvira Gamboa, Licensee who accompanied LPA on a tour of the home, inside and outside, as shown on the facility sketch. Licensee is Spanish Speaking. Days and hours of operation are Mon-Fri 05:00 AM – 06:00 PM. The areas of the home that are accessible to the daycare children are the daycare room & daycare restroom. “Off-limits” rooms are made inaccessible by closed/locked sliding door. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medications and other hazardous items are inaccessible to children. There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment were observed. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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. Adequate supervision is being provided during this inspection. LPA observed accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Children are supervised when outside in the play area and there are no hazards to children present. Capacity as specified on the license is being maintained. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter Espinoza	TELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMBOA, ELVIRA FAMILY CHILD CARE	FACILITY NUMBER: 543904576
	VISIT DATE: 01/25/2022

NARRATIVE

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There is a working telephone and cellphone number was verified. LPA reviewed a sample of children’s files, which were complete with emergency information as required. Licensee maintains documentation of immunizations for influenza, pertussis, and measles for herself and staff. Licensee’s Pediatric CPR/First Aid are current expiring on 05/15/2022. Licensee’s Mandated Reporter training certificate was completed on 02/28/2021. Licensee is aware that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advanced notice.

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.

Incidental Medical Services (IMS) are not currently being provided. 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

LPA & Licensee discussed the Community Care Licensing (CCL) website (www.ccld.ca.gov) which provides access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, Forms, and Regulations. Licensee stated she is receiving PINs and updates through email. LPA discussed infant items permitted in Family Child Care Homes and left a visual handout. LPA provided Licensee with the “Effects of Lead Exposure” brochure in accordance with AB 2370, Chapter 676, Statutes of 2018.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

(Continued on LIC 809-C)

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter Espinoza	TELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMBOA, ELVIRA FAMILY CHILD CARE	FACILITY NUMBER: 543904576
	VISIT DATE: 01/25/2022

NARRATIVE

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Exit interview conducted and report was reviewed with Elvira Gamboa, Licensee.

A notice of site visit was given and must remain posted for 30 days.

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: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter Espinoza	TELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMBOA, ELVIRA FAMILY CHILD CARE	FACILITY NUMBER: 543904576
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(f)

Infant Safe Sleep

An infant shall not be swaddled while in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed swaddled Infant sleeping in play yard Based on observation, the licensee did not comply with the section cited above in 1 infant child which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2022
	Plan of Correction
1 2 3 4	Licensee agreed to stop swaddling infants in care effective today. Deficiency cleared at time of visit.

Type B

Section Cited

CCR

102425(j)(1)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes. 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 for 4 infants in care. Licensee admitted to not documenting sleeping checks for infants every 15 minutes,.which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2022
	Plan of Correction
1 2 3 4	Licensee agreed to start to document 15-minute sleeping checks for children #1, 2, 3, 4 effective today. Deficiency cleared at time of visit.

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: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter Espinoza	TELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMBOA, ELVIRA FAMILY CHILD CARE	FACILITY NUMBER: 543904576
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. 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 for four (4) infants in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2022
	Plan of Correction
1 2 3 4	Licensee agreed to Individual Infant Sleeping Plan (LIC 9227) children # 1, 2, 3, 4 effective today. Deficiency cleared at time of visit.

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: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Peter Espinoza	TELEPHONE: 661-644-8231
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022

LIC809 (FAS) - (06/04)

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