434418056-1-7-2026-07-CC-MKAR-DQ4QGS-20260107111003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434418056
Report Date: 01/07/2026
Date Signed: 01/07/2026 05:34:42 PM

Document Has Been Signed on 01/07/2026 05:34 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GOMEZ TIQUE, DIANA		FACILITY NUMBER:	434418056
ADMINISTRATOR/ DIRECTOR:	DIANA GOMEZ TIQUE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 476-1131
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/07/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:18 AM
MET WITH:	Diana Gomez Tique		TIME VISIT/ INSPECTION COMPLETED:	11:22 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	On January 07, 2026, Licensing Program Analyst (LPA) Mandeep Kaur conducted an announced Prelicensing Inspection in response to a change of location and capacity increase application. LPA met with Applicant, Diana Gomez Tique, and explained to her the purpose of today's inspection. Per Applicant, there are two adults residing in the home: herself and her husband(A1). Licensee is currently licensed for Small Family Child Care Home, facility # 434417720 effective 12/20/2023. Fire Clearance for Large Family Child Care Home was granted on December 26, 2025. Days and hours of operation will be Monday - Friday from 6:30 AM to 5:30 PM. Applicant submitted proof of completion in Health and Safety class including Nutrition and Lead Poisoning Prevention. Applicant's Mandated Reporter Training was completed on June 18, 2024. Applicant's immunizations in measles, pertussis, and flu are on file. Applicant's Pediatric CPR/First Aid certifications expire on June 07, 2027. Applicant has current liability insurance on file that expires on November 26, 2026 and applicant understands that parents will need to fill out the Affidavit Regarding Liability Insurance (LIC 282) if she does not plan on obtaining liability insurance for the day care in the future. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149). Continuation on next pages:

NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ TIQUE, DIANA	FACILITY NUMBER: 434418056
	VISIT DATE: 01/07/2026

NARRATIVE

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LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed barricaded
fireplace, gated kitchen, fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide
detectors. Off limit areas inside the home: kitchen, 3 rooms, one bathroom in a room, dining room, and garage. The home is clean and orderly, with heating/air conditioning, and ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children. Applicant states that there are no weapons in the home and there is a pet (dog) and fully vaccinated. Off limit areas outside: both sides of the home and the barricaded area of the right side backyard. LPA observed barricaded AC unit in the back yard of the home. There were no bodies of water observed.

Forms of discipline to be used by Applicant: talking to children and redirection. Cleaning products, toxic
agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking,
baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

Applicant understands that children's personal rights should not be violated; including no corporal
punishment. Isolation of sick children, supervision of children, capacity options, transportation of children,
requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and
requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills
must be practiced at least once every 6 months and documented.

Facility will provide the food to the children. Healthy Beverage requirements were discussed and copy is provided to the Applicant. Applicant was advised to label the food containers and any water bottles those are brought from the children home, with children names.

Applicant, Diana Gomez Tique, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ TIQUE, DIANA	FACILITY NUMBER: 434418056
	VISIT DATE: 01/07/2026

NARRATIVE

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LPA discussed the requirements of Assembly Bill(AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed
"zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate
$500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100
per day continues until the violation(s) is corrected.

LPA discussed the safe sleep regulations with Applicant 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 Applicant 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.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes,
children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was
provided to the applicant.

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) or (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.

On this date, December 18, 2025, the California Attorney General - Megan's Law website was searched for
information on sex offenders required to register with local law enforcement under California Megan's Law.
No registered sex offenders found at the facility addresses. Under state law, some registered sex offenders
are not subject to public disclosure; therefore, they may not have included in this search. However, the
Department conducts a monthly cross reference of each address on record for all registered sex offenders
against all CCLD facility addresses pursuant to information shared by California DOJ.

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NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ TIQUE, DIANA	FACILITY NUMBER: 434418056
	VISIT DATE: 01/07/2026

NARRATIVE

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Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families
obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs)
throughout California. For additional resources, please contact Santa Clara County Office of Education at (669) 212-5437 or via email at childcarescc@sccoe.org.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and
stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other
important information communication platform. To receive important licensed-related information to licensed
facilities, visit the CCLD Important Information website at
https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option
to receive email communication.

As a result of this inspection, a license for a Large Family Child Care Home for 14 children is granted effective January 9, 2026.

Exit interview conducted and report was reviewed with the Applicant, Diana Gomez Tique. Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Mireya Flores
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026

LIC809 (FAS) - (06/04)

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