406215924-10-10-2024-17-CC-MSAN-D9WTTV-20241010150121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406215924
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:01:38 PM

Document Has Been Signed on 10/10/2024 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	DOMINGUEZ FAMILY CHILD CARE		FACILITY NUMBER:	406215924
ADMINISTRATOR/ DIRECTOR:	MARIA ELENA DOMINGUEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 369-2127
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 8	DATE:	10/10/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Maria Dominguez		TIME VISIT/ INSPECTION COMPLETED:	03:10 PM

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On 10/10/24, at 12:45 PM, Licensing Program Analyst (LPA) Matthew Sapien conducted an unannounced Annual Random inspection of the abovementioned Family Child Care Home (FCCH). LPA met with Maria Dominguez, Licensee of the FCCH, and explained the nature and purpose of the inspection. The LPA, in the company of Licensee, toured the interior and exterior of the FCCH. The house is a 3-bedroom and 2-bathroom single story home. The home's living room, dining area, hallway bathroom, and front yard are used for child care services, while the remainder of the home is excluded (three bedrooms, laundry room, garage, additional bathroom, and backyard). At the time of the inspection, eight children were present, as well as a staff assistant (cleared and on facility roster).

LPA observed the FCCH to be orderly and clean. The bathroom, utilized for care, is clean and free of toxins. Bathroom cabinets and mirror contain child safety locks and latches. The LPA observed personal medication and sharps in elevated cabinets in the kitchen area out of reach of children. Moreover, cleaning compounds were also observed in the kitchen area in a lower cabinet secured by a child safety lock making the cleaning supplies inaccessible to children in care.

LPA observed age-appropriate toys, books, furnishings, and other equipment throughout the living room of the FCCH.

LPA observed appropriate licensing forms and documents posted prominently to a bulletin board in the home's living room. LPA observed smoke and carbon monoxide detectors throughout the FCCH. The carbon monoxide detector was tested at 12:48 PM, while the smoke detector was tested at 12:51 PM. Both detectors were found to be operational. LPA also observed a regulation fire extinguisher in the FCCH, which was last serviced on 2/6/24.

(CONT. 809-C, Page 2)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE	FACILITY NUMBER: 406215924
	VISIT DATE: 10/10/2024

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LPA reminded the Licensee to service or purchase a regulation fire extinguisher yearly. LPA reviewed the FCCH's fire/disaster drill log. The most recent disaster drill occurred on 9/5/24.

As noted previously, the front yard is accessible to children in care. The FCCH's front yard is enclosed by wooden fencing, as well as children safety gates. The fence’s entry/exit gates are secure. Like the interior of the FCCH, the front yard has age-appropriate play structures, furnishings, and other equipment throughout the area. The footing in the front yard area is made up of varying surfaces (natural grass and concrete pavement). The Licensee was reminded to replace toys and play equipment which start to degrade or are not in good repair. The Licensee informed LPA that children in care are directly supervised when engaged in outdoor activities. LPA observed and confirmed with the Licensee that there are no bodies of water on site.

LPA reviewed children's records. The records are current, complete, and possessed emergency contact information and immunization records, among other relevant licensing documents and forms. The Licensee's records were also viewed. The Licensee’s Pediatric CPR and First Aid certifications (EMSA approved) expiring on 4/23/26 and their Mandated Reporter Training, expiring on 4/16/26, is current and complete as are other relevant licensing forms and documents. Licensee was reminded to renew certifications and training prior to expirations. The Licensee informed LPA that there are no firearms and ammunition stored on site.

The Licensee informed LPA that Licensee does not currently provide medication nor Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see PIN 22-02CCP. 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) or (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.

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
(CONT. 809-C, Page 3)

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE	FACILITY NUMBER: 406215924
	VISIT DATE: 10/10/2024

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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.

Licensee 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, 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.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility when the LPA completed a RSO profile in FAS on 10/10/24.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Maria Dominguez.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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