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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376626280
Report Date: 03/08/2023
Date Signed: 03/08/2023 03:01:36 PM

Document Has Been Signed on 03/08/2023 03:01 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:GOMEZ, CYNTHIA FAMILY CHILD CAREFACILITY NUMBER:
376626280
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 3DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cynthia GomezTIME COMPLETED:
03:15 PM
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On 03/08/2023 at 01:40 PM, Licensing Program Analyst (LPA), Dana Stevens conducted an unannounced Annual Required Inspection and met with licensee Cynthia Gomez. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Licensee's mother/assistant and 3 daycare children were also present at the time of the inspection. Licensee accompanied LPA throughout the inspection of this 2 bedroom, 1 bathroom home. The following areas are used for child care: living room, and bathroom. Off-limits areas are kitchen, 2 bedrooms and backyard. These areas are made inaccessible with door knob covers, safety gate and door locks. The front yard is used for outdoor activities, licensee stated total supervision is provided.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements.  The licensee has toys, play equipment and materials available. Licensee stated there are no weapons in the home. A review of records on this date indicates that all individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Licensee's CPR/First Aid certification expires 08/2023. Licensee's assistant's First Aid and CPR certifications expire 11/2023. LIcensee's and Assistant's Mandated Reporter training was completed 11/2021. Facility roster and children's files were reviewed and found complete.  The last fire and disaster drill was documented on 11/2022.



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.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GOMEZ, CYNTHIA FAMILY CHILD CARE
FACILITY NUMBER: 376626280
VISIT DATE: 03/08/2023
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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 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

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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

No deficiencies cited.

Exit interview conducted and copy of report and appeal rights were provided to the licensee and their signature on this form acknowledges receipt of these rights.

A notice of site visit was given and must remain posted for 30 days

SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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