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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004106
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:53:30 PM

Document Has Been Signed on 07/21/2022 03:53 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOMEZ, CYNTHIA R.FACILITY NUMBER:
384004106
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cynthia GomezTIME COMPLETED:
04:10 PM
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On 7/21/2022 at 1:45PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Cynthia Gomez. Purpose of the inspection was explained and was for an unannounced; Annual Random inspection. Present in facility was the licensee and two children (School Age). Per licensee, school age children present are her daughters. All adults have their criminal record clearance on file. Licensee’s home is a two bedroom, one bathroom, one level apartment. Days and hours of operation are: Monday- Friday, 8:00 AM. to 5:00 PM. LPA inspected home with licensee for health and safety hazards.

At 1:55PM., the following was observed: day-care was clean, orderly, and with age appropriate playthings available for the children. Furniture and toys inspected were in good repair. Licensee had a child sized table and chairs for snack and activities. Accessible windows and fireplace in playroom have been barricaded. For napping services, stackable cots (6) and playpens (2) are stored in playroom. Playpens inspected had the proper sized mattress with tight-fitting sheet. Bathroom #1 was observed clean with adequate supplies. Fixtures tested were in operating condition. Off-limit areas had been made inaccessible with child safety gate and doors. Electrical outlets have been covered. Poisons, detergents, cleaning compounds, medicines, and other items (which could pose a danger if readily available) are stored inaccessible to children. Facility was the proper temperature, with adequate ventilation, and lighting. Home had functioning telephone; smoke/ carbon monoxide detector combo; and one fire extinguishers (2A:10BC) located in facility kitchen. Home does not have any swimming pools, spas, hot tubs, fishponds or other bodies of water. (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOMEZ, CYNTHIA R.
FACILITY NUMBER: 384004106
VISIT DATE: 07/21/2022
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(Page 2)
At 2:20PM., LPA reviewed the facility and children’s records. Children's records included the: Identification of Emergency Information (LIC700); Consent for Medical Treatment (LIC627); Immunization Records; Notification of Parent’s Rights (LIC995A); and Signed 'Individual Infant Sleeping Plan', (LIC9227).

Licensee maintains required infant napping logs, documenting each 15- minute check.


Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring 6/2023. Licensee is conducting emergency disaster drills every six months, with last drill on, 7/13/2022, properly logged.

Posted in entry way, including: Facility License; Notification of Parent’s Rights; and Emergency Disaster Plan (LIC610A). Children's Roster (LIC500) was reviewed during inspection. Per licensee, isolation of an ill children will be in the playroom.

LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labeled. Per licensee, home does not have any firearms.

Licensee was reminded that all adults 18 years and over, living or working in the home, including employee and volunteers, must obtain criminal 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.

LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOMEZ, CYNTHIA R.
FACILITY NUMBER: 384004106
VISIT DATE: 07/21/2022
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(Page 3)
Based on today's inspection, no deficiencies were observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview and report was discussed with Licensee, Cynthia Gomez, and signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must be posted for 30 days.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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