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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423681
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:29:16 AM

Document Has Been Signed on 07/08/2022 11:29 AM - 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:
07/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ISABEL GOMEZTIME COMPLETED:
11:45 AM
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10:00AM Licensing Program Analyst Tasha Alexander met with Isabel Gomez for a 2nd ANNOUNCED RE-LOCATION INSPECTION. The purpose of today's visit is to inspect the interior of applicant's home since it has been determined by the department that the applicant is not allowed the use of her basement for the sole/primary use for day care. Present for today's inspection is Ms. Gomez, her assistant Vanessa and 3 preschool age children in care. The home is a one story house consisting of 3 bedrooms, 1 bathroom, living room, kitchen, laundry area, basement/garage and backyard. The living room, bathroom, 3rd bedroom, kitchen and backyard will be used as the primary areas for day care. Applicant understands that the basement and is ONLY to be used as an extension of play due to extreme weather, for example, if it is raining outside and children are unable to play outside or if it is extremely hot. The small cottage/play area is only to be used as a play area for children during outside playtime and not a primary day care area.
The off limit areas will be now be the 2 bedrooms located near the front door and the basement/garage. These areas will be inaccessible to children in care by closed/and or locked doors and visual supervision and safety gates. Applicant and her husband own the home; proof was shown. There is a 3A40BC fire extinguisher, working smoke detector and working carbon monoxide detector; all located in the kitchen area; recommended periodic servicing. Per applicant, there are no firearms in the home. There are no pools, hot tubs or other bodies of water at the home. All sharp knives, cleaning solutions and medications are inaccessible to children. First aid kit is available and complete. The isolation area for sick children will be an area located in the living room. Outdoor play will be in the backyard which is completely fenced. 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 First aid training which expires 9/5/22. Applicant has completed her 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
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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: 07/08/2022
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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

TODAY THERE ARE NO DEFICIENCIES CITED. THIS HOME WILL BE LICENSED AS OF TODAY 7/8/22.

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

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
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