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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416068
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:34:13 PM

Document Has Been Signed on 07/13/2022 04:34 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:POMPA, DIOSELINAFACILITY NUMBER:
274416068
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 0DATE:
07/13/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dioselina PompaTIME COMPLETED:
04:40 PM
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Licensing Program Analysts (LPAs) Teodoro Trujillo and Fermin Campos-Jaramillo met with Applicant, Dioselina Pompa, to conduct an announced pre-licensing inspection. LPAs were granted access to the home by the Applicant. No children were present in the home during today's inspection. The Applicant and her adult children, Jose Yovani, Yuritzi are the adults residing in the home. There are two minor children residing in the home ages 9 and 15.

Days and hours of operation will be Monday - Friday from 05:00 AM to 6:00 PM, Saturday 05:00 AM to 1:00 PM. Applicant completed her Preventative Health and Safety Child Care Training on 03/31/22 and a copy of the certification is on file. Applicants CPR and First Aid certifications are current and expire on 03/19/2024. Copies of both certifications are on file. Applicant completed the Mandated Reporter Training for Child Care Workers on 03/09/2022 and a copy of the certification is on file. A copy of current TB test, flu, Mmr, and Tdap vaccinations for the Applicant are on file. Applicant rents the home and a copy of the lease agreement verifying control of property and Owner/Landlord Notification (LIC 9151) form is on file. Applicant does not have liability insurance and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282).

LPA toured the indoor and outdoor areas of the home with the Applicant during today's inspection. The Applicant's home is single story and LPA observed no stairs inside the home. There are no wall heater units in the home, there is a inoperable fireplace covered with furniture. Off limit areas inside the home: 4 bedroom and one bathroom and attached garage. Off limits outside: Front yard.

The report continues on page 2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: POMPA, DIOSELINA
FACILITY NUMBER: 274416068
VISIT DATE: 07/13/2022
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This report continues from Page 1.
The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (2A10BC) and working combo smoke and carbon monoxide detectors, fenced backyard, and no bodies of water. Applicant states that she do not have any weapons/ammunition in the home. Applicant states that she does not have any pets in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. Applicant states that there are no poisons in the home. LPA reminded Applicants that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in the corner by the living room area if necessary due to illness or communicable disease. Applicant has a First Aid kit with a contact thermometer in the home.

Applicant understands that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Diosilina Pompa, 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, 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 requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

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SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: POMPA, DIOSELINA
FACILITY NUMBER: 274416068
VISIT DATE: 07/13/2022
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This report continues from Page 2.
LPA provided and reviewed 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.

LPA provided and discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Applicant 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
APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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)/ (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

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

A Small Family Child Care Home (FCCH) license will be approved pending on the following:
1. Licensee needs to fix 3 small spots broken in back yard fence.
2. Approval from Licensing Program Manager.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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