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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416709
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:10:00 PM

Document Has Been Signed on 04/06/2022 02:10 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:DOMINGUEZ GUZMAN, GUADALUPEFACILITY NUMBER:
434416709
ADMINISTRATOR:GUADALUPE DOMINGUEZ GUZMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 767-1618
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 9DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Guadalupe Dominguez GuzmanTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Licensee Guadalupe Dominguez Guzman and explained the reason for the inspection. Present during today's inspection were 9 children, whom two were infant age, Licensee, and one Assistant. All adults present have cleared fingerprints.

There is a board to post required postings. The hours of operation are Monday through Friday 7AM to 5PM. There is working phone in the home.

LPA toured in the inside and outside of the home with Licensee. The off-limit areas of the home are the master bedroom, bedroom 1, bedroom 2, and garage. There is a fireplace in the home, which is barricaded. Disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. LPA reminded Licensee to ensure that any cleaning supplies or disinfectant wipes are out of reach of children. There is sufficient amount of toys for the children. There are play yards for each infant and was observed to be in good condition. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Licensee stated that there are no weapons, such as firearms, stored in the home. Licensee does have a dog.

Licensee stated that her backyard is temporarily off-limits, since she is adding artificial turf. She stated that she will take a picture once it is completed. There is play structure in the backyard, which is anchored to the ground. LPA did not observe any bodies of water during today's inspection. Licensee stated that she is going to be making a left section of the patio off-limits. Licensee stated that she will send an updated LIC 999A once it is completed.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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: DOMINGUEZ GUZMAN, GUADALUPE
FACILITY NUMBER: 434416709
VISIT DATE: 04/06/2022
NARRATIVE
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LPA observed at 10:32AM that there were two infants sleeping in their own individual play yard. One of the infants had a blanket in the play yard with them. Licensee removed blanket during inspection. LPA reviewed the infant sleeping log during today's inspection. Licensee stated that she will go over the PIN regarding safe sleep with her assistant. A copy of the PIN was provided to Licensee during today's inspection. 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 does not provide Incidental Medical Services (IMS). LPA observed that C-3 had a doctor's note on file about an inhaler. Licensee stated that she will follow-up with parents about the inhaler. 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: http://www.ada.gov/childqanda.htm

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.

A copy of the facility roster was obtained. Nine children's files were reviewed. The records reviewed include but not limited to immunization record and LIC 9227. C-1 did

----------------------------continues on 809 dated 04/06/2022 page 3-----------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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: DOMINGUEZ GUZMAN, GUADALUPE
FACILITY NUMBER: 434416709
VISIT DATE: 04/06/2022
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-----------------------continuation of 809 dated 04/06/2022 page 2-----------------------------

not have LIC 9227 on file. Licensee stated that she will obtain LIC 9227 and send proof to Licensing. LPA observed that C-2 had the top portion of the LIC 995: Notification of Parent's Right, but no the bottom. Licensee stated that she will obtain bottom portion of LIC 995.

Licensee and her Assistant's file were also reviewed. Her assistant last completed the Mandated reporter training on 08/09/2021 and Licensee last completed the Mandated Reporter training on 03/09/2020. LPA reminded Licensee that the Mandated Reporter training requires renewal every two years. Licensee stated that she will complete the Mandated Reporter training and send proof to Licensing. Licensee and her assistant have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 12/01/2022 and her assistant's expires on 07/10/2023. LPA observed immunization record for assistant on file. Licensee's immunization records are on file.

The adults 18 years old and over are Licensee and her spouse. All adults have cleared criminal record, child abuse index, and TB clearance. 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.

Licensee stated that she will submit a copy of her lease agreement to Licensing.

As a result of this inspection, three Type B citations, one technical violation, and one technical assistance were issued. Exit interview conducted and report was reviewed with the licensee Guadalupe Dominguez Guzman. 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: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 02:10 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/06/2022 at 12:30 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: DOMINGUEZ GUZMAN, GUADALUPE
FACILITY NUMBER: 434416709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There was one infant sleeping who had blankets in the play yard, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2022
Plan of Correction
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Deficiency was correct during today's inspection. Licensee removed blankets during today's inspection.
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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 people, which poses a potential health, safety or personal rights risk to persons in care. Licensee last completed the Mandated Reporter training on 03/09/2020.
POC Due Date: 05/23/2022
Plan of Correction
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By POC 05/23/2022, Licensee stated that she will complete the Mandated Reporter training and send proof to Licensing.
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: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/06/2022 02:10 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/06/2022 at 12:30 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: DOMINGUEZ GUZMAN, GUADALUPE
FACILITY NUMBER: 434416709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

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 record reviewed, the licensee did not comply with the section cited above in 1 out of 2 children, which poses a potential health, safety or personal rights risk to persons in care. C-1 did not have form on file.
POC Due Date: 04/13/2022
Plan of Correction
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By POC 04/13/2022, Licensee stated that she will have C-1's parent fill out form and send proof to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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