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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312270
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:43:51 PM

Document Has Been Signed on 09/04/2025 02:43 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GOMEZ, LAURA SILVIAFACILITY NUMBER:
304312270
ADMINISTRATOR/
DIRECTOR:		GOMEZ, LAURA SILVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 923-9182
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/04/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Licensee, Laura Silvia Gomez TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) A. Nunez. LPA met with 1 of the licensee’s assistant. Licensee Laura Silvia Gomez arrived at the facility at 12:29 pm. LPA observed 3 adult assistants and 7 children of whom 3 children were under 24 months old and 4 children were preschool age children. LPA and licensee, toured the facility inside and outside. Licensee was operating within the capacity of Large Family Childcare Home.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

According to licensee, currently there are three adults including the licensees, and 1 minor child living in the house. Day care hours of operation are Monday through Friday from 6:15am – 6pm.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas which were accessible during LPAs visit were also observed. The off limit areas that were currently available to children included two bedrooms and converted garage. The master bedroom was not observed as this room was locked and inaccessible. The childcare area consists of a living room, converted dining area, 1 bathroom that is located down the hall on the left side. There is an outside covered patio area that is also used as a children’s day care area. There are working carbon monoxide, smoke detectors, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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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)
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, LAURA SILVIA
FACILITY NUMBER: 304312270
VISIT DATE: 09/04/2025
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danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. Licensee stated there is no smoking allowed in the home. The facility does have a fireplace but it’s covered with a large thick wooden cover that makes it inaccessible to the children. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use an enclosed back patio for outdoor play, LPA inspected the back patio and found to be in compliance.

There is an in ground swimming pool in the back yard in the day care area. LPA and the licensee, toured the in ground swimming pool inside and out and tested the equipment.


The following was observed to make sure the in ground swimming pool meets the new requirement for the new pool safety regulation that went effective as of 1/1/2025.
LPA observed the following:
1- Pool mesh fencing met the requirement by mesh fencing of minimum height of 60 inches, and maximum vertical clearance of 2 inches from the ground to the bottom of the enclosure.
2- An access gate that opens away from the pool and is self closing with a self latching, key lockable device placed no lower that 60 inches above the ground.
3- No gaps or voids that can allow the passage of a sphere with a diameter equal to or greater than 4 inches. 4- Free of handholds or foothold that could enable a child to climb over.
5- An alarm that sounds upon detecting an entrance into the water which was compliant by ASTM International Standard F2208. The licensee tested the alarm and was operable.
8- A life ring with a minimum of exterior diameter of 17 inches and was labeled by the United States Coast Guard.
8- A rescue pole by the pool area with a body hook and a minimum length of 12 feet.
9- Daily inspection log was not completed.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, LAURA SILVIA
FACILITY NUMBER: 304312270
VISIT DATE: 09/04/2025
NARRATIVE
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The licensee does have a current roster of children in care. Fire Drill was available. The last fire drill was conducted 4/12/2025. Children’s records for children enrolled were reviewed. Ten files were reviewed. There were log for every 15 minutes check on napping children under 24 months old. LIC 9227 (Individual Infant Sleeping Plan) for infants under 12 months old were reviewed. Licensee and the assistant's files were also reviewed. They were all in compliance.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against measles for licensee were in compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

Incidental Medical Services (IMS) policy was discussed. For 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: https://www.ada.gov/resources/child-care-centers/.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, LAURA SILVIA
FACILITY NUMBER: 304312270
VISIT DATE: 09/04/2025
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The licensee understand they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training.

Licensee, Mahdipour Shamloo, Masoumeh 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 clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance before working 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 discussed the safe sleep regulations with Licensee, Mahdipour Shamloo, Masoumeh 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,

https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep,

LPA also informed Licensee, Mahdipour Shamloo, Masoumeh of the importance of checking for recalled as 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

Licensee, Mahdipour Shamloo, Masoumeh 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. 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.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, LAURA SILVIA
FACILITY NUMBER: 304312270
VISIT DATE: 09/04/2025
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To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 on this inspection.

A notice of site visit was given to Licensee Laura Silvia Gomez, and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to post will result in Civil Penalties of $100.00.

Exit interview conducted and report was reviewed with the Licensee, Laura Silvia Gomez .

End of Report. Page 5 of 5

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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