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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416385
Report Date: 08/13/2021
Date Signed: 08/13/2021 12:30:54 PM

Document Has Been Signed on 08/13/2021 12:30 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, LISETTE & MARISOLFACILITY NUMBER:
434416385
ADMINISTRATOR:GOMEZ, LISETTE & MARISOLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 603-5063
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lisette & Marisol Gomez, LicenseesTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), James Santos conducted an unannounced Required 1 Year Inspection visit today. LPA met with Licensees, Lisette & Marisol Gomez and explained the purpose of the visit. There were nine (9) day care children in the home: Two (2) infants and seven (7) preschool age. The home has 2 bedrooms and 1 bathroom.

LPA toured the home inside and out with the Licensee. The home’s operating schedule is Monday through Friday from 6AM to 6PM. The home has a working telephone service. The License, Notification of Parents’ Rights, Emergency Disaster Plan, and Earthquake Preparedness Checklist are posted prominently in the home. The home was observed to be clean and organized. There were sufficient toys and play equipment for the day care children. Cleaning compounds, sharp objects, medications, and other similar items were secured. Bathroom used by children was observed to be clean and in good operating condition. The home has first aid kit, fire extinguisher, smoke and carbon monoxide detector. Off limit area in the home is the garage. Per Licensee, there are no weapons and poisons in the home.

Off limit area outside the home is a locked storage shed. The outdoor playground area is surrounded and enclosed by a fence. Both playground and backyard areas were observed to be well maintained and free of hazards. The playground equipment were observed to be in good condition. There are no bodies of water observed.

LPA obtained an updated copy of the roster of children in care. Children's records were reviewed which include Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice and Immunization record.

Staff records were reviewed which include fingerprint clearance, TB clearance, immunization (Measles, Pertussis, and Flu) record, CPR/First Aid and Mandated Reported Training.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GOMEZ, LISETTE & MARISOL
FACILITY NUMBER: 434416385
VISIT DATE: 08/13/2021
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LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person. LPA also discussed with Licensee the Safe Sleep Regulations.

Care providers are encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources on Regulations, Adoptions of new laws, pay annual fees etc. Mandated Reporter Training can be accessed atwww.mandatedreporterca.com.

Per Licensee, they are not planning to provide (Incidental Medical Services) IMS at this time. 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.


No deficiencies cited during today's inspection. A copy of this report was provided to the Licensee.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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