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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243904693
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:46:57 PM

Document Has Been Signed on 07/07/2021 03:46 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CAREFACILITY NUMBER:
243904693
ADMINISTRATOR:GAMA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 383-6804
CITY:MERCEDSTATE: CAZIP CODE:
95341
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Gama - LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/7/21 Licensing Program Analysts (LPAs), Joseph Pacheco and Roman Iglesias conducted an unannounced Annual Required Inspection and were met by Licensee, Maria Gama. Days and hours of operation are Monday – Saturday, 4:00am – 8:30pm.
LPAs toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the bedroom, kitchen, bathroom, living room and dining room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locks. LPAs observed a water fountain in the backyard that was not fenced. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.
There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. The home has working telephone service and LPA confirmed the phone number is (209) 383-6804.
There are currently two infants in care. LPAs discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes but has not been documenting any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan has not been completed. Infants up to 12 months of age are placed on their backs for sleeping.
Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced. Capacity as specified on the license is being maintained.
CONTINUED ON 809-C
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CARE
FACILITY NUMBER: 243904693
VISIT DATE: 07/07/2021
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Licensee has a current roster of the children. An emergency fire/disaster drill has been completed and documented within the last 6 months. Licensee’s Mandated Reporter Training was completed on 6/2/21. Licensee’s pediatric CPR/First Aid expires on 08/2021. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. Children’s files were reviewed. LPAs observed Children’s files that did not contain the Emergency Consent form and Notification of Parent’s Rights form.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

Upon receipt of a Type A violation, 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. A copy of LIC 9224 was given to licensee.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/07/2021 03:46 PM - It Cannot Be Edited


Created By: Joseph Pacheco On 07/07/2021 at 01:38 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CARE
FACILITY NUMBER: 243904693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited
CCR
102417(g)(5)

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Operation of a Family Child Care Home. 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. This regulation was not met as evidenced by
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Licensee has agreed to fill the pond with rocks within one inch of the rim of the fountain and submit proof to Community Care Licensing by 7/8/21.
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LPAs observation. LPAs observed a water fountain filled with water that was not fenced. The water fountain was approximately 42 inches off the ground and 8 inches deep. This is an immediate health, safety or personal rights risk to children in care. A $500 civil penalty was assessed.
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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:Diana deLeon
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2021 03:46 PM - It Cannot Be Edited


Created By: Joseph Pacheco On 07/07/2021 at 03:10 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GAMA, MARIA & OLMOS,MARIA FAMILY CHILD CARE
FACILITY NUMBER: 243904693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
102417(g)(7)

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Operation of a Family Child Care Home. An emergency information card shall be maintained for each child and shall include...the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement was not met as evidenced by LPAs observation.
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Licensee has agreed to have parents complete the required form by 7/21/21. A return inspection will be required.
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LPAs observed Children’s files that were missing the Consent for Emergency Medical Treatment form. This is a potential risk to the health, safety or personal rights of children in care.
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Type B
07/21/2021
Section Cited
CCR102419(d)(1)

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Admission Procedures and Parental and Authorized Representative's Rights. The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A…The bottom portion of this form must be kept in the child’s file as proof that the parent
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Licensee has agreed to have parents complete the required form by 7/21/21. A return inspection will be required.
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or authorized representative has been notified of his or her rights. This requirement was not met as evidenced by LPAs observation. LPAs observed Children’s files that were missing the Notification of Parent’s Rights form. This is a potential risk to the health, safety or personal rights of children in care.
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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:Diana deLeon
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
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