543909506-8-9-2023-57-CC-TMAZ-CUJVB8-20230809161708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 543909506
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:17:15 PM

Document Has Been Signed on 08/09/2023 04:17 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	DOMINGUEZ, ELODINA FAMILY CHILD CARE		FACILITY NUMBER:	543909506
ADMINISTRATOR:	DOMINGUEZ, ELODINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(559) 627-1350
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 4	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Elodina Dominguez		TIME COMPLETED:	04:30 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	On 8/9/2023, Licensing Program Analyst (LPA),Theresa Marquez conducted an unannounced Annual Required Inspection and was met by Elodina Dominguez. Also present was licensee’s assistant Maricela Romero. Licensee is English/Spanish Speaking. LPA toured the home inside and outside and a census was taken. LPA reviewed current facility sketch and confirmed that the child care room, living room, dining area, and hall bathroom are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of safety gates. Days and hours of operation are Monday - Friday, 7:30 AM - 6:00 PM. This is a single level home and there are no stairs. Safe toys and play equipment are observed. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained. There is no swimming pool or other bodies of water on the premises. LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 8/25/2021. Licensee’s pediatric CPR/First Aid certification expires on 11/30/2023. A review of records indicates that licensee and or employees/ volunteers have immunization records on file for influenza, pertussis and measles. LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2). Continued on LIC-908-C

SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: DOMINGUEZ, ELODINA FAMILY CHILD CARE	FACILITY NUMBER: 543909506
	VISIT DATE: 08/09/2023

NARRATIVE

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Elodina Dominguez was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed safe sleep regulations with licensee Dominguez and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Dominguez 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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee Dominguez was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
Continued on LIC 809-D

SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/09/2023 04:17 PM - It Cannot Be Edited

Created By: Theresa Marquez On 08/09/2023 at 03:37 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: DOMINGUEZ, ELODINA FAMILY CHILD CARE	FACILITY NUMBER: 543909506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee could not provide evidence of the above required immunization. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Licensee stated she has a scheduled Dr. appointment this month and will inquire with her physician if she can obtain the required immunization or received a letter of exemption. Licensee will submit proof to the Fresno licensing office of either proof of immunization or an exemption letter signed by her physician by 8/31/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Luisa Gavoutian

LICENSING EVALUATOR NAME:

Theresa Marquez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: DOMINGUEZ, ELODINA FAMILY CHILD CARE	FACILITY NUMBER: 543909506
	VISIT DATE: 08/09/2023

NARRATIVE

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Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: Licensee does not have evidence of required immunizations: Pertusis and Measles. (see page LIC809-D.

An exit interview was conducted and report was reviewed with the Elodina Dominguez. During the exit interview, Dominguez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A copy of the evaluation report, Appeal Rights and the Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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