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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364819926
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:29:08 PM

Document Has Been Signed on 10/13/2021 12:29 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GORE FAMILY CHILD CAREFACILITY NUMBER:
364819926
ADMINISTRATOR:GORE, LINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 272-1512
CITY:VERDEMONTSTATE: CAZIP CODE:
92407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Linda Gore, LicenseeTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Maddox met with licensee, Linda Gore for the purpose of conducting and unannounced Annual/Random inspection. Present today were licensee, her husband, and 3 children (2 day care children and 1 grandchild). The home is a single story family home with 4 bedrooms and 2 bathrooms. **There are no pools, spas or any other bodies of water on the premises. All adults in the home (licensee and husband only) have fingerprint clearances, exams for T.B., and required immunization's. Licensee is associated to the Early Child Care Headstart unit with Child Care Resource Center. The family room; backyard; 2 bedrooms; and the front bathroom are designated for child care.

Fireplace is screened and home has central heating and air conditioning. The kitchen and bathroom were toured and inspected for proper storage of chemicals, detergents, cleaning compounds, medications and sharp pointed objects, all items were made inaccessible to children. The outside play area was clear of chemicals and debris, the entire yard is fenced. All unused electrical outlets are plugged and play equipment and toys are available. Licensee is aware that baby walkers, bouncer, or any similar equipment are prohibited in any licensed facility.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GORE FAMILY CHILD CARE
FACILITY NUMBER: 364819926
VISIT DATE: 10/13/2021
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Licensee and her husband have current CPR and First Aid training (exp 11/2022) and Mandated Reporter training is current (exp 8/15/23). Per licensee, there are no weapons or firearms of any kind on the premises. The required fire extinguisher (2A 10BC), smoke detector, and carbon monoxide devises are all in operable condition. Licensee has a current Roster and documentation of Disaster drills

*LPA observed all required forms posted; Regulation prohibits the smoking of tobacco in any licensed facility.
*The licensee is reminded of the requirement to report and unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC 624B.
*LPA reviewed a sampling of children's files today, all files contained required documents including current immunization's.

**LPA disseminated new Safe Sleep requirements (including printing out updated Regulations) and explained form LIC9227 and the requirement to document care and supervision of Infants every 15 minutes.
******Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 o Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: - None enrolled at this time.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GORE FAMILY CHILD CARE
FACILITY NUMBER: 364819926
VISIT DATE: 10/13/2021
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**Each report (documenting a Type A citation) shall remain posted for 30 days along with the Notice of Site Visit (printed out during this inspection). Family child care homes shall post during hours of operation. **Failure to meet the posting requirements shall result in an immediate $100.00 civil penalty. In addition; all parents of currently enrolled children and any newly enrolled child for the following 12 months shall receive a copy of report documenting the Type A citation and sign form LIC 9224 acknowledging receipt. Civil Penalty assessments will be assessed if all above requirements are not adhered to. Staff is aware of required forms for children's files and forms that shall be posted after licensure.
Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov - Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months


Exit interview conducted, copy of report was given to Licensee during this inspection.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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