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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610558
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:24:38 PM

Document Has Been Signed on 09/10/2024 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:DOMINGUEZ, ANA MARIA FAMILY CHILD CAREFACILITY NUMBER:
136610558
ADMINISTRATOR/
DIRECTOR:		ANA MARIA DOMINGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 545-0309
CITY:IMPERIALSTATE: CAZIP CODE:
92251
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
09/10/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Ana Maria Dominguez, ProviderTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On September 10, 2024, at 10:30 a.m., Licensing Program Analyst (LPA), D. Sanchez, conducted an unannounced Annual Random Inspection and met with the Licensee, Ana Maria Dominguez. Licensee is a Spanish speaker and inspection was conducted in Spanish language. PA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Eleven (11) children and three (3) staff and provider were present in the facility during this inspection. This facility is a two story, three bedroom, 2.5 bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: living room, dining room, hallway bathroom and backyard. Off limits areas are: second floor, laundry room, kitchen and garage and are inaccessible through use of door knob protection and baby gate.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. All hazardous items were inaccessible to children. The storage area for poisons is locked. The licensee has toys, play equipment and materials available. The home has a fenced backyard available for outdoor activities. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee’s First Aid and CPR certifications expire on 07/2025. Licensee has required immunizations. Licensee completed Mandated Reporter Training on 3/2023. Facility roster is maintained and was reviewed. The last fire and disaster drills were conducted and documented on 07/2024.

There is one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards are free from all loose articles and objects. The provider physically checks on sleeping infants every 15 minutes. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] is maintained for each infant up to 12 months of age. The provider places infants up to 12 months of age on their backs for sleeping.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Diana Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOMINGUEZ, ANA MARIA FAMILY CHILD CARE
FACILITY NUMBER: 136610558
VISIT DATE: 09/10/2024
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LPA provided and discussed the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. One of the facility staff has been working at this facility since 2022 and is fingerprint clear, but not associated to this facility. Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided handouts with information regarding upcoming Safe Sleep Regulations/SIDS, Lead exposure and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

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.

California Code of Regulations, (Title 22, Division 12 & Chapter 3), are being cited on the attached LIC 809-D.

Upon Receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted with the licensee. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Diana Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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Document Has Been Signed on 09/10/2024 12:24 PM - It Cannot Be Edited


Created By: Diana Sanchez On 09/10/2024 at 12:04 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DOMINGUEZ, ANA MARIA FAMILY CHILD CARE
FACILITY NUMBER: 136610558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in 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 one of the facility staff who is fingerprint clear but not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Provider Ana Maria Dominguez, stated that she will ensure to associate the staff by tomorrow. Provider will ensure to call the San Diego Child Care Regional Office (SCCRO) to ensure staff has been associated to the facility, before admitting staff back to work.
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:Jason Garay
LICENSING EVALUATOR NAME:Diana Sanchez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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