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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019040
Report Date: 06/22/2023
Date Signed: 06/22/2023 12:22:37 PM

Document Has Been Signed on 06/22/2023 12:22 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:DOMINGUEZ FAMILY CHILD CAREFACILITY NUMBER:
198019040
ADMINISTRATOR:DOMINGUEZ, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 213-7077
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Michelle DominguezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elka Chavez conducted an unannounced 1-year required inspection to the above facility. LPA arrived at the facility at 8:50 AM and met with Licensee, Michelle Dominguez who guided analyst on a tour of the facility. Also present was Assistant, Cathlene Murphy. Entrance Checklist for Family Child Care Homes was provided to the licensee. There were 4 children present upon arrival. Hours of operation are Monday through Friday from 7:00 AM to 5:00PM.

This is a single-story home which consists of 3 bedrooms, 2 bathrooms, living room, dining room, kitchen, back room (daycare room) next to the detached garage and backyard (fenced). Areas accessible to children are: Living room, kitchen, dining area, bathrooms, daycare room and backyard (fenced). Areas off limits to children and parents are: 3 bedrooms and front yard. LPA observed a trampoline in the backyard. LPA advised adult supervision is required when utilizing the trampoline. At 8:55 AM LPA observed an above ground pool in the backyard which is accessible to children and parents. Parents and children enter the premises through the backyard. All off-limit areas need to be made inaccessible to children in care. The licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Licensee was informed that the detached garage can only be used for activities. No eating or napping. Food is provided by the Licensee.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019040
VISIT DATE: 06/22/2023
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Parent Rights and LIC 999A Facility Sketch or equivalent sketch. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 7/13/22.

At 9:00 AM smoke and carbon monoxide detectors were tested and are operable in the playroom and the home. LPA observed the fire extinguisher indicated fully charged, last serviced in October of 2022. The home maintains telephone service via landline that is transferred to the licensee’s cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate material available for children. LPA observed central air and heat in the facility. LPA observed that detergents, cleaning compounds are kept in the laundry room next to the kitchen in a top cabinet and are inaccessible to children. Licensee was reminded that all poisons must be locked. LPA advised that if a child shows signs of illness, he/she/they shall be separated from other children. Per Licensee there are no firearms or weapons stored in the home.

Licensee cares for one infant. Napping equipment does not block entrances or exits. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the play yard. There are currently no infants with pacifiers. Each infant has their own play yard and bedding. Licensee does not provide any overnight care at this time.

Currently, children are using the backyard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed an above ground swimming pool in the backyard. LPA observed the ladder was removed and not attached to the pool. LPA observed the Licensee move the ladder to the side of the yard which is gated and inaccessible to children in care. LPA observed the wall to the pool to be 3 feet 11 inches in height. LPA did not observe a fence surrounding the pool. LPA observed the pool is 13 steps away from the entrance used by parents and children in care. Licensee stated that the pool is only used during the summertime. Daycare children do not use the pool.

Children’s records were reviewed for Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months).

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization against
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019040
VISIT DATE: 06/22/2023
NARRATIVE
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measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate.

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

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 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/process.

Licensee, Michelle Dominguez 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 Michelle Dominguez 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 Maria Felix 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: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019040
VISIT DATE: 06/22/2023
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Based on the LPA’s observations, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety. Technical violations must be corrected to ensure the health and safety of children in care.

LPA Elka Chavez informed licensee Michelle Dominguez that this report dated 6/22/23 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Elka Chavez informed the licensee Michelle Dominguez to provide a copy of this licensing report dated 6/22/23 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Michelle Dominguez.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Elka Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2023 12:22 PM - It Cannot Be Edited


Created By: Elka Chavez On 06/22/2023 at 11:50 AM
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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102417(g)(5)(B)
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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (B) Where an above-ground pool structure is used as the fence or where the fence is mounted on top of the pool structure, the pool shall be made inaccessible when not in use by removing or making the ladder inaccessible or erecting a barricade to prevent access to decking. If a barricade is used, the barricade shall meet the requirements of Section 102417(g)(5)(A).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA observed an above ground pool in the backyard 13 steps away from the entrance used by children and parents, the pool wall is 3 feet 11 inches in height. LPA did not observe a fence, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee will install a mesh fence that sorrounds the pool and will use the bodies of water job aide provided by LPA.

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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2023 12:22 PM - It Cannot Be Edited


Created By: Elka Chavez On 06/22/2023 at 11:50 AM
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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198019040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

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 last drill was conducted on 7/13/233, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Licensee stated that she will set a reminder on her phone to test the alarms every 6 months.

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:Karen Chambers
LICENSING EVALUATOR NAME:Elka Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


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