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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215578
Report Date: 07/19/2021
Date Signed: 07/19/2021 11:30:14 AM

Document Has Been Signed on 07/19/2021 11:30 AM - 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
426215578
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kashia GomezTIME COMPLETED:
11:40 AM
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On 7/19/2021 at 10:00 AM, Licensing Program (LPA) Analyst Francisca Velazquez and Licensing Program Manage (LPM) , Maria Mueller conducted a required Inspection of the facility. Prior to entering the facility, LPA completed COVID-19 pre-screening questionnaire with Licensee and based on LIcensee's responses it was determined that facility did not have COVID-19 exposures. LPA and LPM met with Kashia Gomez, Licensee of the facility and explained the purpose of the inspection. LPA and LPM in the company of Licensee toured the interior and exterior of the facility. This home is a two (2) story home. Licensee stated that children in care have access to the first level of the home and the second level of the home is inaccessible to the children. LPA and LPM observed a small gate at the bottom of the stairway making the second floor inaccessible. At the time of inspection 1 child was present along with Licensee's spouse Pedro Gomez. During inspection another child arrived for care.

LPA and LPM observed a clean home with plenty of activities for the children in care. The bathroom used for care was clean and free of toxins. LPA and LPM observed cleaning compounds stored in a high cabinet in the kitchen. LPA observed that all low cabinets in the kitchen have additional safety latches. LPA observed knives, sharps and Licensee's medication is stored in a high cabinet in the kitchen and are inaccessible to children in care. Toys, furniture and equipment in the facility are age appropriate.

Licensee uses the back yard as an outdoor play area. LPA and LPM observed that backyard is completely fenced. Licensee stated that when children play outdoors, children are always supervised by Licensee or assistant. LPA and LPM observed a jacuzzi in the backyard that is inaccessible to children. Licensee stated that jacuzzi is not in use and has not been in use for a few years. Licensee opened Jacuzzi and LPA and LPM observed that there was no water in the Jacuzzi. LPA and LPM observed a locked shed in the backyard. Licensee stated that the shed has children items, gardening equipment, and toxins. LPA and LPM reminded Licensee that shed should always be locked and inaccessible to children in care.
CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215578
VISIT DATE: 07/19/2021
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LPA and LPM observed required licensing forms and documentation posted on the refrigerator in the kitchen. LPA and LPM observed smoke detector and carbon monoxide detector in the wall of the kitchen. Both smoke detector and carbon monoxide were tested and were found to be operational at 10:08 AM. LPA observed a regulation fire extinguisher in the playroom of the facility that was purchased on 1/12/21. LPA and LPM reminded Licensee to either service or purchase a regulation fire extinguisher annually. LPA and LPM reviewed the facility emergency drill log. Last drill facility conducted was 2/21/21. LPA and LPM reminded Licensee that emergency drills need to be completed and documented every six (6) months.

Licensee stated that there are no firearms or ammunition stored in the facility.

LPA and LPM reviewed a sampling of the children records. All records reviewed are current and contains complete emergency card information. Facility has a current roster of children enrolled in the facility. LPA and LPM reviewed Licensee's Pediatric CPR and Frist-aid certification which expires 6/5/2022 and AB1207 and Mandated Reporter training certificate which expires 8/25/22.

Licensee stated that she does not provide medication in the facility. 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: www.ada.gov/childqanda.htm

LPA and LPM discussed COVID-19 guidance and best practices with the Licensee. LPA and LPM discussed safe sleep regulations with the Licensee. In addition, Individual Infants Sleep Plan LIC 9217 was discussed. Licensee stated that at the moment Licensee is not providing care to infants and is aware of the new safe sleep regulations.

There were no Title 22 deficiencies cited during this visit.

LPA provided Licensee with LIC 9213 (Notice of site visit). Licensee posted LIC 9213 prior to LPA and LPM leaving the facility.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
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