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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376621746
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:50:12 PM

Document Has Been Signed on 01/09/2024 03:50 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:DOMINE, MAE FAMILY CHILD CAREFACILITY NUMBER:
376621746
ADMINISTRATOR:MAE DOMINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 822-7021
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
01/09/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Mae DomineTIME COMPLETED:
03:45 PM
NARRATIVE
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On January 9, 2024, at 1:40 p.m., Licensing Program Analyst (LPA), Gloria Gonzalez conducted an unannounced Required 3-year Inspection and met with Licensee, Mae Domine.  LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee.  Seven (7) daycare children and one (1) helper was present in the facility during this inspection. This facility is a one story, 2 bedroom, one bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. The following areas used for child care are: kitchen, dining room, living room, bedroom #2, bathroom, and front yard.  Off limits areas are master bedroom and is made inaccessible and LPA was not able to verify if garage was made inaccessible. Hours of operation are: Monday-Friday 8:00 pm-5:00 pm.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements.  Hazardous items were made inaccessible to children during the inspection. The licensee has toys, play equipment and materials available. The home has a fenced front yard available for outdoor activities at time of inspection. No bodies of water observed on the premises during the inspection. Licensee stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

Licensee’s First Aid and CPR certification expires on 12/2/25.  Licensee has required immunizations.  Licensee completed Mandated Reporter Training on 10/11/22.  Licensee's helper did not have a Mandated Reporter Certificate. Facility roster is maintained and was reviewed.  The last fire and disaster drills were conducted and documented on 9/5/23.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 01/09/2024 03:50 PM - It Cannot Be Edited


Created By: Gloria Gonzalez On 01/09/2024 at 02:52 PM
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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: DOMINE, MAE FAMILY CHILD CARE
FACILITY NUMBER: 376621746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a Mandated Reporter Certificate for helper #1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee states she will send the department a copy of the Mandated Reporter Training Certificate for Helper #1 by 1/31/24 by email.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [count] out of 2 out of 3 infants had the LIC9227, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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LIcensee states she will send the department a copy of the LIC9227 for Child #1 by 1/31/24 by email.
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:Tulam Vu
LICENSING EVALUATOR NAME:Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOMINE, MAE FAMILY CHILD CARE
FACILITY NUMBER: 376621746
VISIT DATE: 01/09/2024
NARRATIVE
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There is one crib or play yard for each infant who is unable to climb out of the crib or play yard.  Cribs or play yards are free from all loose articles and objects. Licensee physically checks on sleeping infants up to 24 months of age every 15 minutes.  2 out of 3 infants had an Individual Infant Sleeping Plan [LIC 9227 (3/20)] and must be maintained for each infant up to 12 months of age.  Licensee states she places infants up to 12 months of age on their backs for sleeping. 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 and discussed the following:  Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms.  Licensee was reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.  Licensee was also provided information regarding SIDS, Lead exposure and Shaken Baby Syndrome.

LPA and Licensee discussed California Megan's Law and LPA provided:www.meganslaw.ca.gov.  During the exit interview, Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA advised if there is an unusual incident to report to call Licensing within 24 hours and to follow up with an LIC624B within 7 days. In addition, for general questions, questions regarding licensing requirements call Child Care Licensing.

Duty Line at (619) 767-2248. Access our updated Regulation & Forms by using our WEBSITE: http://ccld.ca.gov.

LPA discussed and provided Licensee with the following: child care advocates email address: childcareadvocatesprogram@dss.ca.gov.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: DOMINE, MAE FAMILY CHILD CARE
FACILITY NUMBER: 376621746
VISIT DATE: 01/09/2024
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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: https://www.ada.gov/resources/child-care-centers/.

LPA advised the Licensee that prior to making alterations or additions to the home or grounds, the Licensee shall notify the Department of the proposed change.

Licensee was informed of the MyChildCarePlan.org website; 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.

Type B deficiencies are being cited during today's inspection, see LIC809D.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
 
A copy of the report, appeal rights (LIC 9058), and notice of site visit (LIC9213) was provided to Licensee and advised must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA interpreted and explained the inspection report to licensee in Spanish, licensee stated she understood.

An exit interview was conducted and report was reviewed with the licensee, Mae Domine.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Gloria Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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