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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585405085
Report Date: 01/02/2024
Date Signed: 01/04/2024 12:24:38 PM


Document Has Been Signed on 01/04/2024 12:24 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:VILLAGOMEZ, IRMA FAMILY CHILD CARE HOMEFACILITY NUMBER:
585405085
ADMINISTRATOR:VILLAGOMEZ, IRMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 434-6124
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY:14CENSUS: 4DATE:
01/02/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Irma VillagomezTIME COMPLETED:
01:15 PM
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On 1/2/2024 at 9:25am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Laura Chavez. Upon arrival to the home LPA observed Infant #1 sleeping in an automatic infant swing covered by a blanket. At 9:45am the home was toured inside and outside. The licensee and assistant were supervising four children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:00am - 5:00pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The garage and second story of the home are off-limits to children in care and were made inaccessible by a baby gate and lock. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

Five children's records were reviewed at 10:40am. During children's file reviews LPA found that a file was not available for Infant #5. There are currently two adults living in the home.

The following deficiencies were cited: 102425(i) Safe Sleep, 102419(j), 102418(g), 102417(g)(7), 102417(m)(3), 102425(c)(2) and 102425(j)(2), see LIC 809D):

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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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Document Has Been Signed on 01/04/2024 12:24 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in one out of one infant observed covered in a blanket while sleeping in automatic swing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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The licensee agrees that she and her assistant will review Title 22 Regulations and view the Departments website (https://ccld.childcarevideos.org) regarding Safe Sleep. After reviewing and viewing information on safe sleep the licensee agrees to provide a written statement on how she and her assistant will ensure following the Department's Safe Sleep requirements. The licensee agrees to provide a plan of correction no later than 1/3/2024.
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2024 12:24 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(j)
Admission Procedures and Authorized Representatives Rights
(j) Copies of the signed receipt shall be available to the Department as provided in Section 102391(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 1 out of 5 children file reviews which potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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The licensee agrees to provide a completed copy of Infant #5's Notification of Parents’ Rights (LIC 995A). The plan of correction shall be submitted on or by 2/1/2024.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 1 out of 5 children file reviews which posses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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The licensee agrees to provide a copy of Infant #5's current immunizations. The plan of correction shall be submitted on or by 2/1/2024.
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2024 12:24 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 1 out 5 children file reviews which poses a potential health, safety or personal rights risk to persons in care. An emergency information card (LIC700) was not available for review.
POC Due Date: 02/01/2024
Plan of Correction
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Licensee agrees to provide a copy of Infant #5's emergency information card (LIC700) to CCLD on or before 2/1/2024.
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
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Based on record reviews, the licensee did not comply with the section cited above in 1 out 5 children file reviews which poses a potential health, safety or personal rights risk to persons in care. An affidavit (LIC282) was not available for review.
POC Due Date: 02/01/2024
Plan of Correction
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Licensee agrees to provide a completed copy of the affidavit for Infant #5 (LIC282) to CCLD on or before 2/1/2024.
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2024 12:24 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
An Individual Infant Sleeping Plan [LIC9227 (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. The Individual Infant Sleeping plan shall be maintained in the infant's file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 1 out 5 children file reviews which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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The licensee agrees to provide a completed copy of Infant #5's Individual Sleep Plan. The plan of correction shall be submitted on or by 2/1/2024.
Type B
Section Cited
CCR
102425(j)(2)
The provider shall supervise infants while they are sleeping and adhere to the following requirements. The provider shall check and document every 15 minutes while the infant sleeps.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 2 out of 2 infant file reviews which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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The licensee agrees to submit two weeks of the required 15 minute safe sleep documentation for Infant #1 and #5. The plan of correction shall be submitted to CCLD on or before 2/1/2024
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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085
VISIT DATE: 01/02/2024
NARRATIVE
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LPA Laura Chavez informed licensee Irma Villagomez that this report dated 1/2/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Laura Chavez informed the licensee to provide a copy of this licensing report dated 1/2/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.



To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085
VISIT DATE: 01/02/2024
NARRATIVE
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Licensee Irma Villagomez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee Irma Villagomez and her assistant Norma Villagomez 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 the licensee and her assistant 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: VILLAGOMEZ, IRMA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585405085
VISIT DATE: 01/02/2024
NARRATIVE
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Licensee Irma Villagomez was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, licensee Irma Villagomez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with licensee Irma Villagomez.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Laura ChavezTELEPHONE: (530) 895-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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