434416709-4-5-2023-07-CC-SYIP-CQLQZA-20230405123625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416709
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:36:32 PM

Document Has Been Signed on 04/05/2023 12:36 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, GUADALUPE		FACILITY NUMBER:	434416709
ADMINISTRATOR:	GUADALUPE DOMINGUEZ GUZMAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 767-1618
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	04/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Guadalupe Dominguez Guzman		TIME COMPLETED:	12:45 PM

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 Required- 1 Year inspection. LPA met with Licensee Guadalupe Dominguez Guzman and explained the reason for the inspection. Present during today's inspection were four children, whom one was infant age and two were Licensee's own children. There is an area to post required posting, such as license and notification of parent's rights. The hours of operation are Monday through Sunday 7AM to 5PM. Licensee uses her cell phone. LPA toured the inside and outside of the home. The off-limit areas of the home are the master bedroom, bedroom 1, bedroom 2, and the garage. LPA reminded Licensee that the any rooms that are off-limit need to be closed, such as the master bedroom. Disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. LPA reminded Licensee that blenders need to be inaccessible to children. There are toys for children. 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. The last fire/disaster drill was conducted on 10/23/2022. LPA reminded Licensee that fire/disaster drill need to be conducted every 6 months. Licensee does have dog. The backyard is used. The off-limit areas outside is the left and right side of the yard. Licensee stated that they are currently not using the backyard due to the ------------------continues on 809 dated 04/05/2023 page 2------------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: 04/05/2023

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
26
27
28
29
30
31
32

-----------------continuation of 809 dated 04/05/2023 page 1-----------------

storms and have not used the backyard since 12/2022. There is a fence in the backyard. There is a section of the fence on the left back corner that fell and the back section of the fence is leaning. Licensee stated that
she is currently working with her landlord to get it fixed. There is play structure outside, which is anchored to the ground. LPA discussed with Licensee to ensure that anything that collect water needs to be dumped out and any animal feces needs to be picked up. LPA observed that there is padding on the bottom of the play structure below the wooden ladder, which is come out beyond the length of the play structure. This could create an tripping hazard. Licensee stated that she will have her husband tuck it in, so it does not create a tripping hazard.

LPA reviewed the 15 minute sleep check. 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 transport children, but understands that children cannot be left alone and unattended in parked vehicles.

Licensee currently does not have children who required Incidental Medical Services (IMS). For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes 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

-------------------continues on 809 dated 04/05/2023 page 3---------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: 04/05/2023

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
26
27
28
29
30
31
32

----------------continuation of 809 dated 04/05/2023 page 2----------------------

A copy of the facility roster was obtained during today's inspection. Two (2) children's files were reviewed during today's inspection. The records reviewed include but not limited to immunization records and notification of parent's rights.

Licensee has a valid CPR/1st Aid, which expires on 11/05/2024. Licensee completed the Mandated Reporter training on 04/25/2022. Licensee's immunization record are on file.

The adults 18 and older living in the home are Licensee and her spouse. All adults have cleared fingerprints. 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.

As result of this inspection, no deficiencies were issued. Exit interview conducted and report was reviewed with Licensee Guadalupe Dominguez Guzman. A notice of site visit was issued and must remain posted for 30 days.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5