243912992-4-27-2026-04-CC-MDHO-DTJQ45-20260427114946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 243912992
Report Date: 04/27/2026
Date Signed: 04/27/2026 11:50:05 AM

Document Has Been Signed on 04/27/2026 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GOMEZ, AGUSTINA FAMILY CHILD CARE		FACILITY NUMBER:	243912992
ADMINISTRATOR/ DIRECTOR:	GOMEZ, AGUSTINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 930-8262
CITY:	LOS BANOS	STATE: CA	ZIP CODE:	93635
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/27/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Agustina Gomez		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/27/26, Licensing Program Analyst (LPA), Martha De Haro and Licensing Program Manager (LPM) Kari McWilliams met with Licensee, Agustina Gomez for a change of location inspection. Licensee was previously licensed at 526 Castlerock CT, Los Banos, CA 93635 with facility number #243912442. Licensee, her boyfriend, two other adults, and one (1) minor child reside in the home. Background clearances are discussed and Guardian Roster was signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance. Fire clearance was granted on 04/24/26. Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed: · Fire clearance was received on 04/24/26. Fire pull alarm is located in the kitchen · On this date, 04/02/2026, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. · This is a two story six (6) bedroom, three (3) bathroom home and upstairs area will be off-limits to day-care children. There is a gate at the top and bottom of the stairs making upstairs area inaccessible. Care and supervision will be provided in the nap room, kitchen, dining room, living room, downstairs bathroom, and backyard. Off-limits rooms are made inaccessible by use of plastic door knob spinners. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Kari McWilliams
NAME OF LICENSING PROGRAM ANALYST: Martha DeHaro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

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 6

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, AGUSTINA FAMILY CHILD CARE	FACILITY NUMBER: 243912992
	VISIT DATE: 04/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

· There is a fireplace in the dining room that applicant states will not be used during day-care hours and is blocked. There is adequate heating and ventilation for safety and comfort.
· Licensee’s Pediatric CPR and First Aid certification was completed through American Safety and Health Institute with Emergency Medical Services Authority (EMSA) stickers and expires on 10/2026.
· Preventative Health and Safety Course with Prevention of Lead exposure certification was completed on 07/13/22. Certificate of Lead Poisoning Prevention was completed on 07/13/22.
· Licensee completed the Mandated Reporter Training for Child Care Providers on 04/02/25.
· SB 792 immunizations have been verified and are on file.
· Licensee rents the home, proof of landlord notification is required. LPA observed the Property Owner/Landlord Notification form (LIC9151) that the Licensee confirms was provided to the property owner/landlord. Licensee obtained a signed Property Owner/Landlord Consent form (LIC 9149).
· There are games, toys, and books for the children. Children will nap in mats and infants will nap in cribs in the nap room. Licensee understands she is to supervise children at all times.
· Fenced backyard has a plastic climbing structure with slide, child sized table, and assorted toys for the children.
· Facility has 2A10BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place. · Knives are stored in an upper cabinet in the kitchen. Medications are stored in a closet in the Master Bedroom upstairs. Cleaning compounds are stored under the kitchen sink in the kitchen. Poisons are stored in a locked shed in the side yard.
· There is an in-ground pool located on the left corner of the back yard that is enclosed with wrought iron fencing. Portions of the fence measured at least five (5) feet tall. However, there were some areas where the pool fence and gate measured about four and a half (4 ½) feet. There is a gate that is self-latching/self-closing, swings away from the pool and the key locking device is located no lower than 60 inches from the bottom of the gate. The gate was not self-closing from a close distance. The maximum vertical clearance was measured less than 2 inches except for one area near the wooden fence, which measured about seven (7) inches. There is a life ring with US Coast Guard Approval that has an exterior diameter measured at 20 inches, and a rescue pole with a body hook that measured over 12 feet. There is also a pool alarm that is functioning when placed in the body of water and is compliant with ASTM International Standard F2208. However, the alarm’s sensitivity needs to be recalibrated. The in-ground pool is not in accordance with Title 22 Regulations. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Kari McWilliams
NAME OF LICENSING PROGRAM ANALYST: Martha DeHaro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, AGUSTINA FAMILY CHILD CARE	FACILITY NUMBER: 243912992
	VISIT DATE: 04/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

· Licensee states there are no pets in the home or on the premises.
· Licensee states there are no firearms or ammunition in the home or premises.
· Licensee’s fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
· Licensee is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
· Licensee is reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
· Licensee is advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Applicant states the home is smoke-free.
· Licensee is advised Fresno Community Care Licensing Division has inspection authority and can inspect all rooms in the home including garages and/or separate dwellings on the premises.
· Licensee states she will be transporting day care children. Licensee understands that she must have proper car restraints and/or car seats for all the children under her care when transporting children.

LPA discussed the safe sleep regulations with Licensee 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 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. LPA provided Licensee with Individual Infant Sleeping Plan and Safe Sleep handout.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (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 (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Kari McWilliams
NAME OF LICENSING PROGRAM ANALYST: Martha DeHaro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, AGUSTINA FAMILY CHILD CARE	FACILITY NUMBER: 243912992
	VISIT DATE: 04/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

LPA reviewed with licensee the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant. Licensee was advised that she may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. Licensee is also reminded that it is her responsibility to read the regulations periodically. Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. Licensee states she will operate her day care Monday through Sunday, open 24 hours. Overnight care will be provided. “Overnight Care" means care being provided to children anytime between the hours of 6:00 PM and 6:00 AM. Care provided during the day and overnight combined shall not exceed 24 hours from the time the child entered into care.

Community Care Licensing Division (CCLD) 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-carelicensing/subscribe and select the Child Care option to receive email communication.
(Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Kari McWilliams
NAME OF LICENSING PROGRAM ANALYST: Martha DeHaro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, AGUSTINA FAMILY CHILD CARE	FACILITY NUMBER: 243912992
	VISIT DATE: 04/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee is advised the following items must be corrected and documentation to be sent to Fresno CCL within the next 30 days to avoid possible withdrawal:

· Spring on pool gate to be adjusted so that it is self-closing from short and far distances
· All panels on wrought iron fence to be adjusted so that they measure at least 5 feet tall all around the pool
· Dirt surface on left side of pool near wooden fence to be raised so that it measures no less than 2 inches from the bottom of the dirt to the fence enclosure
· Sensitivity on pool alarm to be adjusted so that it goes off if something falls in the water
· Licensee to provide Tuberculosis (TB) test results for the three (3) adults in the home
· Licensee to complete and provide Live Scan transfer forms for the three (3) adults in the home

Pending verification of corrections of the above items and a final review of her application, licensure as a Large Family Day Care Home capacity of 14 children ages under 18 years will be recommended.

Exit interview conducted and report was reviewed with the licensee.

NAME OF LICENSING PROGRAM MANAGER: Kari McWilliams
NAME OF LICENSING PROGRAM ANALYST: Martha DeHaro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6