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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414136
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:53:34 PM

Document Has Been Signed on 09/14/2022 03:53 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, ALEJANDRAFACILITY NUMBER:
434414136
ADMINISTRATOR:GOMEZ, ALEJANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 218-2721
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Alejandra GomezTIME COMPLETED:
04:15 PM
NARRATIVE
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On 09/14/2022 at 8:50 AM, Licensing Program Analysts (LPA) Teodoro Trujillo met with licensee, Alejandra Gomez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and adult daughter Alejandra Arias, with 4 children: two preschool and two infants, at 10:03 a preschool child arrived. Adults living in the home are licensee, her spouse and adult daughter. Days and hours of operation are Monday through Friday 5:00 AM to 5:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/12/2022 was reviewed and it indicates that not all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee tenant who resides in the converted garage has not obtained criminal background clearance. Garage was converted without notification to the San Jose Regional Office. 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 no fireplace inside the home, no wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee has one small dog with current vaccinations. LPA observed a new and fully charged 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on top kitchen cabinet. Off limit areas: three bedrooms and two storage sheds in the 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. 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 09/14/2022 pg. 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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 09/14/2022 03:53 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/14/2022 at 01:16 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, ALEJANDRA
FACILITY NUMBER: 434414136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, licensee tenant, Maria Wang, has not obtained criminal record clearance or exemption as of 09/14/2022,, which poses an immediate health, safety or personal rights risk to persons in care.,
POC Due Date: 09/15/2022
Plan of Correction
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Licensee shall immediately deny access to the converted garage and obtain a criminal record clearance or exemption for Maria Wang, meanwhile she cannot be present in the premises or work until a criminal background or exemption is obtained. .LPA discussed the requirements of AB 633 with licensee Alejandra Gomez and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) LPA explained the use and purpose of the form LIC9224
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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


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Document Has Been Signed on 09/14/2022 03:53 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/14/2022 at 01:16 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, ALEJANDRA
FACILITY NUMBER: 434414136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102370(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Licensee tenant, Maria Wang is missing LIC 508 Criminal Record Clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will obtain a completed Criminal Record Statement LIC 508 from tenant Maria and will submit a copy to the San Jose Regional Office by close of business 09/30/2022.
Type B
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, licensee did not notify the San Jose Regional Office of alterations in the child care home, off limit garage was converted as separate living quarters, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will submit a updated facility sketch to the San Jose Regional Office by the close of business 09/30/2022.
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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


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Document Has Been Signed on 09/14/2022 03:53 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/14/2022 at 01:16 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, ALEJANDRA
FACILITY NUMBER: 434414136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, licensees C1 file is missing LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Licensee obtained completed LIC 9227 form filled and signed by C1 parent on 09/14/2022.
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, Licensee has not started a safe sleep log for C1 and C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee will submit a safe sleep log and a written statement stating she understands the requirements of the safe sleep regulations by close of business 09/15/2022.
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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


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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, ALEJANDRA
FACILITY NUMBER: 434414136
VISIT DATE: 09/14/2022
NARRATIVE
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Continuation of report dated 09/14/2022 pg. 2/3

LPA observed a fire and disaster drill log that was last conducted on 05/04/2022. LPA reviewed 6 children’s files, C1 missing Individual Sleeping Plan LIC 9227, C1 and C2 were missing safe sleep log. The 15 minute check sleep log for infants under 24 months was discussed, licensee was provided a sleep log. LPA observed that the Licensee has Mandated Reporter training, training was completed on with Child Care Providers United on 03/18/2022. Licensee has Pediatric CPR/1st Aid expiring 06/3/2023. 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 web page 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 09/14/2022 pg. 2/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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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, ALEJANDRA
FACILITY NUMBER: 434414136
VISIT DATE: 09/14/2022
NARRATIVE
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Continuation of report dated 09/14/2022 pg. 2/3

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Teodoro Trujillo informed licensee Alejandra Gomez that this report dated 09/14/2022 document(s) one (1)) 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 Alejandra Gomez to provide a copy of this licensing report dated 09/14/2022 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.

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.

Exit interview conducted and report was reviewed in Spanish with the licensee, Alejandra Gomez.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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