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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216576
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:41:40 PM

Document Has Been Signed on 05/31/2023 01:41 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GOMEZ FCCHFACILITY NUMBER:
566216576
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
05/31/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Magdalena Gomez & Heriberto PerezTIME COMPLETED:
01:51 PM
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On May 31st, 2023, at 11:41AM, Licensing Program Analyst (LPA) Rosie Breault conducted an announced inspection for the purpose of performing a pre-licensing inspection. LPA met with applicants Magdalena Gomez and Heriberto Perez and discussed the purpose of the inspection. LPA and applicants together toured the interior and exterior of the home.

During this tour the following was noted:

At the time of the inspection both applicants were present. Residing in the home will be applicants, one (1) family friend (fingerprint cleared), three (3) children aged 15, 8, and 7. Per applicant, the operating hours will be Monday through Friday from 5:00am – 6:00pm.

All areas identified on the facility sketch were inspected. This is a two-story home which consists of four (4) bedrooms, two and a half (2.5) restrooms, one (1) formal living room, (1) informal living room, kitchen, dining room, garage, and outdoor play area. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Off limit areas included: Entirety of second story which consists of four (4) bedrooms and two (2) bathrooms have been rendered inaccessible by gate at bottom of stairs. Garage is inaccessible by lock on door.

Applicants stated that children will have access to both living rooms, half bathroom, dining room, kitchen, and outdoor play area.

CONTINUED ON LIC809C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GOMEZ FCCH
FACILITY NUMBER: 566216576
VISIT DATE: 05/31/2023
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LPA observed age-appropriate toys, play equipment and material for children in care. Knives for family use are made inaccessible by drawer locks, medications and cleaning compounds are located on the second floor. Outdoor play area has age-appropriate toys, soft surface, and shaded area. At the time of the inspection, no bodies of water were present.

The required fire extinguisher 2A10BC was serviced 9/1/2022. Smoke and carbon monoxide detectors were tested at 1:18pm and were functioning at the time of the visit. Applicants were reminded to service or purchase new fire extinguisher yearly. Per applicants, no firearm is present however applicant has one locked inaccessible safe containing ammunition.

The applicants completed the FCCH Orientation on 11/23/2022. The applicants have current Pediatric First Aid and CPR which expires 3/2024. Applicants completed Preventative Health on 11/19/2022. Applicant’s Mandated Reporter expires on 6/29/2024.

LPA reviewed with applicant the LIC311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Applicant 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, 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.

In the absence of the licensee, a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, immunizations, and a valid criminal record clearance associated to the facility license. A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

CONTINUED ON LIC809C

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GOMEZ FCCH
FACILITY NUMBER: 566216576
VISIT DATE: 05/31/2023
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Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home. Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

LPA discussed the safe sleep regulations with applicants, provided applicant with Safe Sleep Information handout, 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 provided applicant: Entrance Checklist, Safe Sleep FAQ’s, Infant Needs and Services Plan (LIC9227), and Sleep Log.

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.

This home meets the Title 22 Division 12 requirements of a small FCCH license effective today 5/31/2023.

An exit interview was conducted, report reviewed, and copy provided to applicants.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Maryrose Breault
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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