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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417109
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:52:35 PM

Document Has Been Signed on 05/24/2023 12:52 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197417109
ADMINISTRATOR:MARTINEZ/GUMERCINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 533-9317
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Gumercinda MartinezTIME COMPLETED:
12:06 PM
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Licensing Program Analyst (LPA) Justin Dorsey met with Licensee,Gumercinda Martinez, who guided analyst on a tour of the facility for the One Year Required Inspection. This is a two story 4 bedroom, 3 bathroom home with kitchen, dining room, family room, living room (converted main care area) and garage. There is no pool on the premises. Upon arrival LPA observed 3 children in care.

Physical Plant: Main care is provided in the living room (main care area). Children use the family room to eat and for infants to sleep if necessary. Children use the downstairs bathroom in hallway near the homes garage. Children have access to the living room, family room, downstairs bathroom and backyard. Off limit area include the homes entire upstairs, kitchen, dining room and garage. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (locked in pantry), medicines (in off limits bedroom) and hazardous items (sharp knives inaccessible in top kitchen cabinet) that can pose a danger to children. Fireplace is screened. The home has safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, and Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/play equipment were observed on the premises. There is a designated area for ill children as necessary in the family room. Per Licensee there are no weapon/firearms in the home. During the visit LPA Dorsey observed 3 cribs with blankets in them, per licensee there are 3 infants enrolled at the home. According to the licensee the infants do not sleep with blankets in the crib and the blankets are placed in the cribs by the older children after they nap.

The last fire/earthquake drill was completed 04/24/23. Roster complete and maintained current.

Bathroom: LPA Dorsey observed the homes children bathroom is free of hazards. Toilet and faucet is clean and operable.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197417109
VISIT DATE: 05/24/2023
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Kitchen: Sharp utensils are inaccessible. Per licensee breakfast, AM snack, lunch, and PM snack are provided. LPA reminded licensee If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. Cleaning supplies are locked in the home pantry. No chemicals in the kitchen were observed to be accessible.

Outdoor: The backyard is safe for children and completely fenced. The backyard has concrete and a padded area under a jungle gym for children to play. LPA observed the toys and jungle gym in the backyard to be in safe condition. LPA Dorsey reminded the licensee to follow the age requirements (3-12 years old and under 150lbs) for the jungle gym. Per licensee the off-limit areas include the right side of the backyard where 3 dogs (Rottweiler) are kept and the grass area.

Advisory/Other: First Aid kit was readily available. CPR/First Aid expire 05/24. Mandated Reporter was completed 05/12/22. Children nap on cots and in cribs in the living room, per licensee at times an infant may sleep in the family room if needed.

Documents discussed: Title 22 Overnight Care 102426, Title 22 Personnel Records 102416.1 Safe Sleep PIN 20-24-CCP, LIC 9227 and Infant Sleep Log.

Licensee Martinez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee Martinez 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 Martinez 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.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MARTINEZ FAMILY CHILD CARE
FACILITY NUMBER: 197417109
VISIT DATE: 05/24/2023
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A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Gumercinda Martinez.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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