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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610649
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:49:09 PM

Document Has Been Signed on 07/29/2024 12:49 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:GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CAREFACILITY NUMBER:
136610649
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
07/29/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Carolina Gaxiola-GastelumTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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On July 29th, 2024, at 9:10 AM, Licensing Program Analyst (LPA), Jo Ann Legaspi conducted an unannounced capacity increase inspection and to inspect the apartment complex neighborhood pool. Licensee Carolina Gaxiola-Gastelum was advised of the meeting’s purpose and granted LPA facility entry. Present in the home was the Licensee and her two (2) children, one child over 10 years.

On 04/26/2024, Licensee submitted an application (LIC 279) requesting a capacity increase. The Fire Safety Inspection Request (STD 850) was approved by the local fire marshal on 07/09/2024 for eleven (11) children. Applicant provided a written statement agreeing to care for only eleven (11) children. Landlord Consent is on file. Applicant has provided written substantiation that they have at least one year of experience as teacher at a licensed childcare center.

This one (1) story, four (4) bedroom, two (2) bathroom downstairs apartment unit was toured and inspected. The following areas are used for care: living room, dining room, patio, one bathroom and one bedroom. . The off-limit areas include the remaining bedrooms, remaining bathroom and kitchen. The kitchen is made inaccessible by use of a child safety gate. The off limit bedrooms and bathroom are accessible through a hallway, which is barricaded with a child safety gate. Doorknobs to the off limit bedrooms and bathroom are covered with a child safety doorknob safety locks. Licensee accompanied LPA on a tour of the home, as shown on the updated facility sketch. Background criminal record clearances were verified and discussed.

First Aid and CPR certifications expire in June 2025. Facility has working 2A10BC fire extinguisher, smoke alarms, carbon monoxide, and the first aid kit in place. The last safety drill was on 05/06/2024. All pools, spas, hot tubs, fishponds, or similar bodies of water are made inaccessible to children by covering or fencing as required by regulation. Applicant provided a written statement declaring that the apartment complex neighborhood pool shall not be used by daycare children. The Licensee states neither animals/pets nor firearms/ammunition are housed in the facility. The daycare schedule is weekdays 4 AM to 4 PM.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 07/29/2024
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The Licensee provided proof of control of property. Because the licensee rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the licensee confirms was provided to the property owner/landlord. The licensee obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Licensee has provided a written statement stating they will care for only eleven (11) children. The Licensee recognizes that the total amount of children simultaneously in the home also includes children who reside in the home. The Licensee acknowledged that if no assistant provider is present at a Large Family Child Care Home, then the Licensee shall comply with the capacity requirements for a Small Family Child Care Home.

Licensees of family day care homes shall ensure that at least one staff member shall always be onsite when children are present at the facility and shall be present with the children when children are offsite from the facility for facility activities. The Licensee shall ensure at least one staff member has a current course completion card in pediatric first aid and pediatric CPR issued by the American Red Cross, the American Heart Association, or by a training program that has been approved by the Emergency Medical Services Authority. Prior to employment or initial presence in the childcare home, all employees subject to a criminal record review shall: obtain a California clearance or a criminal record exemption as required by law or Department regulations or request a transfer of a criminal record clearance. The Licensee shall not employ a staff member if they have not been immunized against influenza, pertussis, and measles. Each employee shall receive an influenza vaccination between August 1 and December 1 of each year. The employee may submit a yearly written declaration attesting that they have declined the influenza vaccination. This exemption applies only to the influenza vaccine. Documentation of immunizations and/or the written declaration attesting the staff have declined to accept the influenza vaccination for that year shall be maintained in the staff’s facility personnel record. The Licensee shall provide each employee with a copy of the Notice of Employee Rights (LIC 9052) form furnished by the Department. Each employee shall be requested to sign and date the notice form acknowledging receipt. A copy of the signed notice form shall be retained in the employee's personnel record. If the employee refuses to sign the notice form, a dated notation to that effect shall be retained in the employee's personnel record.

The Licensee is advised to regularly visit the Community Care Licensing WEB SITE: http://www.ccld.ca.gov/ for quarterly updates and updated regulation information. Community Care Licensing Division (CCLD)
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 07/29/2024
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regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. LPA observed that applicant’s email address has been enrolled into the Department’s email program update notification system. Information about the San Diego Licensing Duty Line was provided. The telephone number to the Licensing Duty Line is (619) 767-2248. Southern California Child Care Advocate (SCCCA) information was provided. Advocate information was provided: (916) 654-1541 and childcareadvocatesprogram@dss.ca.gov

In the areas that were evaluated, no deficiencies were observed. Licensure for a capacity of eleven (11) children is approved today (07/29/2024). A new license will be generated and mailed to the provider.

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the Licensee Carolina Gaxiola-Gastelum.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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