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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423681
Report Date: 04/03/2024
Date Signed: 04/03/2024 04:24:00 PM

Document Has Been Signed on 04/03/2024 04:24 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GOMEZ, ISABELFACILITY NUMBER:
013423681
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Isabel GomezTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:27 PM
NARRATIVE
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On April 3, 2024 at 12:55pm Licensing Program Analyst (LPA) Janai McClain met with Licensee Isabel Gomez to conduct an unannounced annual inspection. Present during today's inspection were the Licensee, her fingerprint cleared spouse - Shaun Aguilera, her fingerprint cleared assistant - Vanesa Rodriguez, and four infants. The licensee lives in the home with her spouse and two small dogs. The operating days and times are Monday - Friday 8:30am-5:30pm. The home was toured for a health and safety inspection.

The home is a two story home family home consisting of four bedrooms, two bathrooms, kitchen, living room, laundry room, garage, converted garage, and fully fenced in backyard. Licensee is reminded to supervise children when the water table is in use.

On Limit Areas - The bedroom adjacent to the living room, living room, kitchen, the upstairs bathroom, the fully fenced backyard, and the converted garage which will be used as a play space.
Off Limit Areas - The two bedrooms at the end of the hallway and the entire downstairs area, including the downstairs bedroom, bathroom, and garage. Off limit areas will be made inaccessible through gates, locked/closed doors, and visual supervision.
Isolation Area - is the couch in the living room.

The home has a fully charged 3A40BC fire extinguisher, a combination smoke and carbon monoxide detector in the kitchen, and a working telephone. The Licensee stated she has Liability Insurance. The Licensee has a Mandated Reporter Certificate which expired on January 18, 2024. The Licensee has a current CPR and First Aid certificate which expires July 2025. The home has heating and ventilation for the safety and comfort of children in care. The Licensee has ample age-appropriate toys and learning materials in the home and in the backyard. Licensee is reminded to make sure toxins, medicines, and hazardous items are inaccessible to children. There were no bodies of water present on the premises. Per the Licensee there are no firearms in the home. *********Report Continues on LIC 809-C********
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681
VISIT DATE: 04/03/2024
NARRATIVE
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LPA reviewed four files and found that the licensee was not logging in each 15 minute check during naps, which is a Type B violation.

LPA provided the Licensee with the Infant Safe Sleep Regulations and a copy of the "Individualized Safe Sleep Plan" (LIC 9227) was provided and reviewed.

Incidental Medical Services (IMS) policy was discussed. The Licensee is currently not providing IMS to the children in care. For IMS information see PIN 22-02. When any IMS is 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

Licensee 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 on 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 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.

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 **********************************Report Continues on LIC809-C********************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681
VISIT DATE: 04/03/2024
NARRATIVE
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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/inspection-process.

During the Exit Interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There was one Type A and five Type B deficiencies issued during today's visit.

Exit interview conducted and report was reviewed with Licensee Isabel Gomez.
Report and Appeal Rights were provided.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Janai McClain
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/03/2024 04:24 PM - It Cannot Be Edited


Created By: Janai McClain On 04/03/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 3 bathroom drawers where medications were accessible and 1 out of 2 kitchen cabinets where cleaning chemicals were accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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During the inspection, licensee moved cleaning chemicals and medications to higher cabinets, making them inaccessible to children. Licensee will review personal rights documentation and email LPA a summary by 04/04/2024.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Janai McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2024 04:24 PM - It Cannot Be Edited


Created By: Janai McClain On 04/03/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill and disaster drill logs, as there was no log on record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will conduct fire and disaster drills and email LPA a copy of the fire and disaster drill logs by 05/03/2024.

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:Mayla Mendoza
LICENSING EVALUATOR NAME:Janai McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/03/2024 04:24 PM - It Cannot Be Edited


Created By: Janai McClain On 04/03/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 Pak n Plays, as the infants were covered in blankets and sleep sacks, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee removed the blankets and sleep sacks during the inspection. Licensee will review the safe sleep regulations and email LPA a summary by 05/03/2024.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 assistants, as assistant Vanesa Rodriguez did not have immunizations on record at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will email LPA a copy of assistant Vanesa Rodriguez's immunizations records documenting TB, pertussis, and measles by 05/03/2024.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Janai McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/03/2024 04:24 PM - It Cannot Be Edited


Created By: Janai McClain On 04/03/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ISABEL
FACILITY NUMBER: 013423681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 infants as there was no LIC9227 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will have the infants parents complete the LIC9227 and email a copy to LPA by 05/03/2024.
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Date, Infant’s name, Time of each 15-minute check, Labored breathing and Signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness, and Infants up to 12 month of age who are sleeping in a position other than on their back. Based on observation, the licensee did not comply with the section cited above in 4 out of 4 infants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will complete the sleep log for infants in care for at least 5 days in a row and email a copy to LPA by 05/03/2024.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Janai McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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