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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394501159
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:35:20 PM

Document Has Been Signed on 06/20/2024 12:35 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RODRIGUEZ GOMEZ, ALEJANDRAFACILITY NUMBER:
394501159
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
06/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Alejandra Rodriguez GomezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 6/20/24, Licensing Program Analyst Carla Polanco (LPA) met with Applicant, Alejandra Rodriguez Gomez (A1) for the purpose of a pre-licensing inspection. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). LPA provided the Entrance Checklist to A1. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA1 accessing Guardian. A1’s tentative hours of care are Monday through Friday, from 6:00 AM until 6:30 PM. A1 does not intend on providing overnight or weekend care at this time.

A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a one-story house with a living room/dining room, kitchen, bedroom #1, bedroom #2, bedroom #3, bathroom #1, play room, bathroom #2, garage and backyard. LPA verified that toxic and hazardous items were inaccessible to children in care. LPA did not observe any stairs. LPA observed a fireplace in the family room that was no properly barricaded. The outdoor play area was toured which includes the backyard which is both cemented and grass. LPA observed that the backyard fence had missing and broken planks. Applicant was advice that the backyard fence had to be fixed before a follow up inspection could be made. LPA also observed access to a small crawl space at the back of the home, while touring the backyard, that leads to the plumbing at the bottom of the home. Applicant was advised to cover the entrance of the crawl space to prevent access by daycare children. LPA did not observe any pool, spa nor water feature. LPA observed a backyard that was in the process of construction work. Applicant states that while construction of the garage is occurring, the area under construction remains inaccessible to children in care. The OFF-limits areas of the FCCH are the bedrooms and the garage. A1 understands that 100% supervision is required for children in the front yard as it is not fenced. A1 stated that she owns two pet cats.


A functioning smoke detector and a functioning carbon monoxide detector were tested in the main hallway. A fire extinguisher was observed in the kitchen, and a first aid kit was observed in the main hallway. A1 stated there are no firearms nor weapons in the home. Continued on 809-C....
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RODRIGUEZ GOMEZ, ALEJANDRA
FACILITY NUMBER: 394501159
VISIT DATE: 06/20/2024
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LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their Mandated Reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. A1 has a current Mandated Reporter Training Certificate which will expire on 04/2026. Current Pediatric CPR and First Aid training was verified and expires on 04/2026. Completion of Preventative Health and Safety training including nutrition and lead exposure was verified before the inspection. Proof of required immunization's for A1 was also verified before the inspection.

LPA discussed the Safe Sleep Regulations with A1 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 A1 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 discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months. LPA provided a copy of the LIC 9227, Individual Sleeping Plan, to be completed for or infants under 12 months.

Incidental Medical Services (IMS) policy was discussed with A1. 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: http://www.ada.gov/childqanda.htm.



Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communications. Continued on 809-C......
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RODRIGUEZ GOMEZ, ALEJANDRA
FACILITY NUMBER: 394501159
VISIT DATE: 06/20/2024
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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

A1 understands that licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.



A1 understands that if she wants to make any Off-limits area an ON-limits area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with Licensee the LIC 311D Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. A1 understands that fire drills must be conducted and documented once every 6 months.


On today's date 6/20/24 the facility was not approved for a small family child care home license. Pending items are:
-Fireplace in the living room must be properly barricaded to prevent access by children in care.
-Backyard fence must be fixed.
-Crawl space at the back of the home must be properly covered to prevent access by child in care.
-Play room with access to the backyard must be organized and hazardous items must be properly stowed away and/or made inaccessible to children in care.

Applicant will be in communication with Department about the above item. Once the above items are reviewed by management, meet Title 22 regulations, and are approved by the Department, the home can be licensed as a Small Family Child Care Home license for a capacity of 8 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above, and 1 child at least age 6. Infants are children under the age of 2. An exit interview was conducted. Appeal Rights were provided.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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