434410646-5-21-2024-07-CC-SYIP-D5GPYY-20240521114442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410646
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:44:52 AM

Document Has Been Signed on 05/21/2024 11:44 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GOMEZ, MARIA		FACILITY NUMBER:	434410646
ADMINISTRATOR/ DIRECTOR:	GOMEZ, MARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 252-6997
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	05/21/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:31 AM
MET WITH:	Maria Gomez		TIME VISIT/ INSPECTION COMPLETED:	11:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Annual/Random inspection. LPA met with Licensee Maria Gomez and her spouse, who also helps with the family child care home. Present during today's inspection were four children, whom were Licensee's grandchildren. There is a board to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Friday 6:30AM to 6PM. Licensee uses her cell phone. LPA toured the inside and outside of the home with Licensee. The off-limit areas of the home are entire second floor and bedroom on the first floor. There are stairs in the home, which are barricaded. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible to children. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Licensee stated that there are no weapons, such as firearms, stored on the premise. The last fire/disaster drill was conducted on 05/19/2024. The backyard is used and is fenced. The off-limit areas outside are the back house, laundry room, and the left side of the yard. LPA discussed with that any off-limit areas need to be inaccessible to children and anything that could pose a risk needs to be inaccessible, such as paint cans. Licensee placed a gate that that leads to the deck behind the home. There were no bodies of water observed during today's inspection. ---------------CONTINUES ON 809 DATED 05/21/2024 PAGE 2-------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, MARIA	FACILITY NUMBER: 434410646
	VISIT DATE: 05/21/2024

NARRATIVE

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-------------CONTINUATION OF 809 DATED 05/21/2024 PAGE 1----------------

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.

Licensee and her spouse do transport children and have valid driver's license. Licensee also understands that children cannot be left alone and unattended in parked vehicles.

Incidental Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/resources/child-care-centers/.

A copy of the facility roster was obtained. Three children's files were reviewed. The records reviewed include but not limited to notification of parent's rights and affidavit. LPA discussed with Licensee that the Affidavit Regarding Liability Insurance needs to be signed by parents if she does not have daycare insurance.

--------------continuation of 809 dated 05/21/2024 page 3---------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, MARIA	FACILITY NUMBER: 434410646
	VISIT DATE: 05/21/2024

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-------------------continuation of 809 dated 05/21/2024 page 2---------------------

Licensee and her spouse have valid CPR/1st Aid, which expires on 05/06/2025. Licensee and spouse completed the Mandated Reporter training on 12/10/2021 and is registered to complete training on 05/21/2024. LPA discussed with Licensee that the mandated reporter training requires renewal every two years, which can be completed through mandatedreporterca.com. Licensee and her spouse's immunization records for measles and pertussis are on file.

The adults living in the home are Licensee, her spouse, and three of her adults children. Licensee also has one minor child and three minor grandchildren who live in the home. All adults have cleared criminal record, child abuse, or exemption. Licensee and her spouse have TB test on record. LPA discussed with Licensee that all adults living in the home need to have TB test and to submit it to Licensing. Licensee was reminded that all adults 18 and over living or working in the home, 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.

An updated LIC 279B was obtained during today's inspection.

Licensee will submit the following by 06/21/2024:
- TB test for her adults children

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Licensee Maria Gomez. A notice of site visit has been issued and must remain posted for 30 days.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 11:44 AM - It Cannot Be Edited

Created By: Samantha Yip On 05/21/2024 at 11:10 AM

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, MARIA	FACILITY NUMBER: 434410646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee and her spouse last completed the Mandated Reporter training on 12/10/2021.
	POC Due Date: 07/01/2024
	Plan of Correction
1 2 3 4	By POC 07/01/2024, Licensee will submit certificate for herself and her spouse to Licensing. Licensee and her spouse are registered to complete training on 05/21/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Segura

LICENSING EVALUATOR NAME:

Samantha Yip

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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