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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423681
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:55:22 PM

Document Has Been Signed on 02/17/2022 01:55 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GOMEZ, ISABELFACILITY NUMBER:
013423681
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
02/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:ISABEL GOMEZTIME COMPLETED:
02:00 PM
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11:20AM LICENSING PROGRAM ANALYST ALEXANDER MET TODAY WITH ISABEL GOMEZ FOR AN ANNOUNCED RE-LOCATION INSPECTION. APPLICANT, HER ASSISTANT TINA AND 3 PRESCHOOL AGE CHILDREN ARE PRESENT FOR THE INSPECTION. THE HOME IS A 1 STORY HOUSE CONSISTING OF 3 BEDROOMS, 1 BATHROOM, LIVING ROOM KITCHEN, LAUNDRY ROOM, BASEMENT ,GARAGE AND BACKYARD. TODAY APPLICANT HAS INFORMED LPA THAT SHE INTENDS TO SOLELY UTILIZE THE HOME'S BASEMENT ,GARAGE AND BACKYARD FOR THE PRIMARY AREAS FOR DAY CARE. THE ENTIRE HOME LOCATED UPSTAIRS WILL BE OFF LIMITS TO CHILDREN IN CARE. TODAY AN INSPECTION OF THE BASEMENT, GARAGE AND BACKYARD WAS CONDUCTED. THE BASEMENT CONSISTS OF ONE ROOM WITH A SINK, SMALL DORM SIZE REFRIGERATOR AND MICROWAVE. THERE ARE COUCHES, PLAY PENS, COTS, SMALL TABLES/CHAIRS, CHANGING TABLE AND TOYS FOR CHILDREN IN CARE. THERE IS A WORKING SMOKE ALARM/CARBON MONOXIDE COMBO LOCATED ON THE BASEMENT WALL. THERE IS A 3A40BC FIRE EXTINGUISHER LOCATED BEHIND THE ENTRANCE DOOR OF THE BASEMENT. RECOMMENDED PERIODIC SERVICING. PER APPLICANT, THERE ARE NO FIREARMS LOCATED ON THE PREMISES THERE IS ONE SMALL WINDOW FOR NATURAL LIGHT AND A SMALL PORTABLE HEATER AND AIR PURIFIER LOCATED ON A TABLE NEAR THE DOOR LEADING TO THE GARAGE FOR HEAT AND VENTILATION. INSIDE OF THE GARAGE THERE IS A BOARDED AREA LOCATED IN THE CORNER WITH A DOOR THAT HOUSES THE TOILET. THE REMAINDER OF THE GARAGE IS GATED OFF BY CHILD SAFETY GATES AND ROOM DIVIDERS TO PREVENT ACCESS TO CHILDREN IN CARE. IN THE BACKYARD, THE GRASS AREA IS FENCED AND THERE IS AN AREA THAT HOUSES PET BIRDS AND PET DOGS PLAY ITEMS FOR CHILDREN.PER APPLICANT, . THERE ARE NO SWIMMING POOLS, HOT TUBS, OR OTHER BODIES OF WATER LOCATED AT THE HOME. ALL SHARP KNIVES, CLEANING SOLUTIONS AND MEDICATIONS ARE INACCESSIBLE TO CHILDREN IN CARE.
CONTINUED ON 809-C
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681
VISIT DATE: 02/17/2022
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FIRST AID KIT IS AVAILABLE AND COMPLETE. THE ISOLATION AREA FOR SICK CHILDREN WILL BE A CORNER AREA IN THE BASEMENT. OUTDOOR PLAY WILL BE IN THE BACKYARD. THERE ARE TOYS AND PLAY SPACE AVAILABLE. APPLICANT WAS INSTRUCTED TO CONDUCT AND DOCUMENT PERIODIC FIRE AND DISASTER DRILLS. APPLICANT WAS INFORMED THAT BABY WALKERS, EXERSAUCERS, AND BABY BOUNCERS ARE NOT ALLOWED. APPLICANT HAS COMPLETED CPR AND FIRT AID TRAINING WHICH EXPIRES 9/5/2022 RESPECTIVELY. APPLICANT HAS COMPLETED 16 HOURS OF HEALTH AND SAFETY TRAINING.

Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies given to applicant. Applicant was instructed on the law establishing a $100 fine per day for adults who are living in the home or who are providing care who do not have fingerprint clearances. Applicant was also instructed on the law requiring notification to parents regarding exclusions.

Individual 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 FAMILY CHILDCARE HOME LICENSE WILL BE ISSUED ONCE CLARIFICATION OF THE REGULATIONS AND CONFIRMATION THAT THE BASEMENT CAN SOLELY BE USED FOR DAY CARE IS CONFIRMED.

AN EXIT INTERVIEW WAS CONDUCTED.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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