543911651-1-10-2022-04-CC-RMAS-CAJSEH-20220110124845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 543911651
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:48:49 PM

Document Has Been Signed on 01/10/2022 12:48 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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GOMEZ, BERTHA FAMILY CHILD CARE		FACILITY NUMBER:	543911651
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	01/10/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Bertha Gomez		TIME COMPLETED:	01:15 PM

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On 01/10/2022 a planned Pre-licensing inspection was made today by Licensing Program Analyst (LPA) Rene Mancinas, who met with Applicant, Bertha Gomez, who is Spanish speaking. A tour of the home, inside and outside, as shown on the facility sketch was done. This is a single-story home. The areas of the home that day-care children will have access to are the daycare room, hallway bathroom, dining room, kitchen, and the front enclosed play area (patio). The remainder of the home is off limits and made inaccessible by means of child safety devices. Applicant and two other adults are the only adults that reside in the home. The LIS 536 was signed indicating that the adults living in the home and/or providing care and supervision to children are background cleared. LPA observed safe indoor play areas, child safety plugs in unused electrical outlets, were all observed. Fire extinguisher, smoke detectors, carbon monoxide detectors and first aid kit are operable and in place. There are firearms and ammunition at this home, which are locked and stored separately as required per regulation. There are no bodies of water (i.e. fountains, swimming pools, etc.) at this home. CPR, first aid training, and health and safety training are current and expiring 03/23/2023. Child Abuse Mandated Reporter Training Completed on 09/20/2021. Postings, forms, and licensing information were provided and discussed. LPA discussed the practice of fire and disaster drills at least every 6 months and to document the date, time and number of children present. There are pets at this home. Licensee understands responsibility of any action taken by pets involving day care children.

Incidental Medical Services (IMS) policy were 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

(Continued on 809-C)

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Rene Mancinas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ, BERTHA FAMILY CHILD CARE	FACILITY NUMBER: 543911651
	VISIT DATE: 01/10/2022

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Applicant 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, 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.

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-andresources/safe-sleep as an additional resource. LPA also informed applicants 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.

This home meets the description of a safe and healthy environment for children as described in Chapter 3, Division 12, Title 22 of California Code of Regulations and licensure for a capacity of up to 8 children. Pending a final review of your application, licensure as a small Family Child Care Home capacity of 8 children* ages under 18 years, will be recommended effective 01/17/2022. Planned hours of operation are 24/7, however, applicant understands she cannot care for a child for a continuous 24 hour period.

Exit interview conducted and report was reviewed with the applicant.
This report shall be made available to the public upon request.
To order forms, etc. visit our website at www.ccld.ca.gov

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Rene Mancinas
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC809 (FAS) - (06/04)

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