Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310833
Report Date: 09/18/2019
Date Signed: 09/18/2019 04:10:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GOMEZ, FLORAFACILITY NUMBER:
304310833
ADMINISTRATOR:GOMEZ, FLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 533-9214
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:14CENSUS: 3DATE:
09/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee Flora Gomez 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
An unannounced annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Barajas and LPA Enciso. LPA’s met with licensee Flora Gomez and toured the entire facility. LPA’s observed 1 infant and 2 preschool age children in day care room. The facility was within licensed capacity and the required ratio. Licensee stated there are presently 3 adults living in the home Licensee, Licensee husband and Adult daughter, no minor children. Day care operating hours are Monday through Friday, 5:30a.m. to 6p.m. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today’s inspection each child was observed to have safe, healthful, and comfortable accommodations, furnishings, and equipment. The floor plan was verified, 1 story home 4 bedrooms and 2 restrooms. Licensee stated all bedrooms, Master Bathroom, living room and kitchen are completely off limits. Off limits areas are made inaccessible by means of baby gates, door knobs and door locks. The children use the back yard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. The front yard is completely off limits. There is a fireplace in the home, its inaccessible due to a blockage of a large wooden bench. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children in garage cabinet locked. Poisonous items are not stored on site, and none were observed during today's inspection. The home provides safe toys, equipment, and materials. There is a working carbon monoxide detector, smoke detector, and fire extinguisher (2A10BC) in the home that meet statutory and State Fire Marshall standards. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months, last one dated 06/12/19. The licensee stated there are no firearms or other dangerous weapons in the home. Bodies of water were not observed during today's visit. The LPA advised the licensee to contact licensing department for any changes to hours and days of planned operation, and for any changes to facility, including on/off limit areas and change in phone number. The licensee has a home phone that is used for child care. The licensee was reminded that if a cell phone is only used, it must remain on the premises always during hours of operation.
Page 1, Continued on Page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, FLORA
FACILITY NUMBER: 304310833
VISIT DATE: 09/18/2019
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
Page 3, Continued on Page 2

LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, baby bouncers, Johnny Jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children record, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby.

The Licensee was given a pamphlet on Lead Exposure and was discussed with provider.

The areas that were evaluated, no deficiencies were observed at the time of the visit. The facility was found to be incompliance with Title 22 regulations during today’s inspection.

Inspection, report review and exit interview was conducted with Licensee Flora Gomez in Spanish. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, FLORA
FACILITY NUMBER: 304310833
VISIT DATE: 09/18/2019
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
Page 2, Continued from Page 1
Children's and staff files were reviewed and in compliance on today’s date.
The licensee stated she is present in the home and ensures that children in care are always supervised. The licensee stated children are not left in parked vehicles. The licensee states when temporarily absent from the home, she arranges for a substitute adult to care for and supervise children in her absence.

The licensee has pediatric CPR/First Aid certification that is current, and both expire on 01/06/2020, with EMS/Pediatric First Aide and meets state regulations under Title 22. Children's records were reviewed for: licensee’s documentation of children’s immunization's on the California School Immunization Card (CDPH 286) and a signed copy of the Family Child Care Home Notification of Parents’ Rights, and in substantial compliance. Proof of immunization against influenza (or written decline) pertussis and measles for licensee(s)/assistants/volunteers were reviewed and within compliance of SB 792. Licensee provided a written declination letter against influenza on today’s date.

Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. The licensee has Mandated Reporter training completed on 03/20/2018.

Incidental Medical Services (IMS) policy was 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

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov A hard copy of the Spring 2019 Child Care Quarterly Update was provided to the licensee. A hard copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee in Spanish. The following electronic links were also provided:
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
Page 2, Continued on Page 3
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3