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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408248
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:14:48 PM

Document Has Been Signed on 03/30/2023 04:14 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GOMEZ, LAURAFACILITY NUMBER:
434408248
ADMINISTRATOR:LAURA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 723-0801
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:TIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Teodoro Trujillo met with licensee Laura Gomez for an annual/random inspection. LPA explained the nature of today's visit to Licensee. Present were one preschool age child, second preschool age child arrived during site visit. Adults living in the home are Licensee, her husband and three adult sons with a 15-year-old child. Days and hours of operation are Monday to Friday, 7:30am to 6:00pm.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 03/28/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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.

LPA inspected inside and outside of the home. LPA observed a glass screened fireplace, no wall heater, no stairs, and three 5 gallon and one 4 gallon buckets filled with water accessible to children. Licensee stated there are no weapons. Licensee stated they have no pets. LPA observed a fully charged 2A10BC fire extinguisher last serviced on 05/25/2022. Carbon Monoxide detector and smoke detectors were operable. LPA observed Listerine mouthwash, sunscreen and adult toothpaste underneath the on-limit bathroom sink, personal grooming items inside the computer desk drawers and a can of compressed air duster and acne personal grooming products in on-limit bedroom closet, accessible to children. Back yard is fenced. Off limits indoor: master bedroom, master bathroom, three bedrooms, and the garage. Off limits outdoor: both side yards. On limit areas: kitchen, living room, day care room, one bedroom, hallway bathroom and rear back yard.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license with an assistant. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.


Continues on report dated 03/30/2023 pg. 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/30/2023 04:14 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/30/2023 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, LAURA
FACILITY NUMBER: 434408248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in personal hygiene products (acne face cleansers) were accessible in the on- limit bedroom closet and bottom left computer desk drawers, mouth wash and tube of sunscreen and adult toothpaste accessible in on limit bathroom sink. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee removed personal hygiene products from bathroom and on limit bedroom stored on top shelf of hallway closet during site visit.
Type A
Section Cited
CCR
102417(g)(5)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above, three 5 gallon and one 4 gallon buckets were filled with water the rim on right side off limit area with no gate, accessible to children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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licensee dumped water from the 5 gallon and 4 gallon buckets and turned them upside down during site visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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Document Has Been Signed on 03/30/2023 04:14 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/30/2023 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, LAURA
FACILITY NUMBER: 434408248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in, bicycles, stacked chairs and back yard furniture, day care furniture are accessible inside the Gazebo in play area for children, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee will submit photo or videdo of Gazebo once all loose furniture has been stored away in storage sheds by close of business 04/07/2023.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Roster has not been updated with date children have left and address for 2 children in care is missing. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Licensee updated roster during site visit, LPA took photo of current roster,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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Document Has Been Signed on 03/30/2023 04:14 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/30/2023 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, LAURA
FACILITY NUMBER: 434408248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 20 month old Infant Child 1 (C1) is missing infant sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee will submit copy of completed sleep log and a written statement of having read and understanding of safe sleep regulations by close of business 04/07/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GOMEZ, LAURA
FACILITY NUMBER: 434408248
VISIT DATE: 03/30/2023
NARRATIVE
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Continuation of report dated 03/21/2023 pg. 2/3

LPA took a picture of roster of the children that needs to be updated, one child has left, and address missing for two children in care. LPA observed a fire and disaster drill log performed on 02/07/2023. LPA reviewed 5 children’s files and observed all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was discussed and 15 minute check sleep log for infants under 24 months was discussed, C1 missing 15-minute infant sleep log has not been started. LPA observed that the assistant Maria has not assisted the child care home, licensee will remove from child care home. Licensee has Pediatric CPR/1st Aid expiring 12/11/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

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.

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/process


Continues on report dated 03/30/2023 pg. 2/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GOMEZ, LAURA
FACILITY NUMBER: 434408248
VISIT DATE: 03/30/2023
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Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Laura Gomez, that this report dated 03/30/2023 document(s) 2 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Laura Gomez to provide a copy of this licensing report dated 03/30/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


Licensee was informed licensee Laura Gomez that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed in Spanish with the licensee, Laura Gomez. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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