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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300957
Report Date: 05/09/2024
Date Signed: 06/17/2024 01:54:37 PM

Document Has Been Signed on 06/17/2024 01:54 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DOMINGUEZ FAMILY CHILD CAREFACILITY NUMBER:
336300957
ADMINISTRATOR/
DIRECTOR:		DOMINGUEZ, SYLVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 834-5034
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Sylvia DominguezTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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On May 9, 2024, Licensing Program Analyst (LPA) Lorena Valenzuela conducted an unannounced inspection at Dominguez Family Child Care Home and met with Licensee Sylvia Dominguez. The purpose of this inspection is to discuss information received during a review of an incident that occurred at the facility.

LPA conducted a visit at the facility on 02/29/20204 and observed Child 1 (C1) an 11-month-old and one year old, Child 2 (C2) in care, asleep on the floor with their heads resting on a pillow with both children being observed not sleeping on their back.

Based on interviews conducted and records review, the Department finds the facility did not comply with the Infant Safe Sleep requirements, due to not ensuring children were asleep in a play yard or crib. Facility is cited under Title 22, Section 102425 (a) Infant Safe Sleep.
An exit interview was conducted, a signed copy of this report, Appeal Rights, and was provided to Sylvia Dominguez.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 06/17/2024 01:54 PM - It Cannot Be Edited


Created By: Lorena Valenzuela On 05/09/2024 at 09:42 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 336300957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
102425(a)

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102425 (a) INFANT SAFE SLEEP.There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.
This requirement was not met as evidence by:
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Licensee states will provide the Department a written statement regarding following safe sleep regulations, and will ensure statement includes information of how will provide training in regard to infant sleep to all assistants. By due date 05/17/2024.
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Based on interviews and observation, the licensee did not ensure sleeping infants in care were placed on a play yard or crib on at least one occasion. This poses a potential risk to the health, safety and personal rights of the 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:Deborah Mullen
LICENSING EVALUATOR NAME:Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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