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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421268
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:54:57 AM

Document Has Been Signed on 05/24/2022 11:54 AM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GOMEZ, ENAFACILITY NUMBER:
013421268
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Ena Gomez and Sulma ZevallosTIME COMPLETED:
12:00 PM
NARRATIVE
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On May 24, 2022, Licensing Program Analyst (LPA) Indira Loza made an unannounced visit for the purpose of conducting a required annual inspection. LPA was met by the licensees daughter Sulma Zevallos. Present for the visit were two infants and three preschoolers. The home was toured to conduct a health and safety inspection. The licensees primary language is Spanish. The facility operates Monday through Friday 8am-5pm.

The facility consists of the unit next to the licensee's home, which has been converted into a child care room. The unit consists of a kitchenette, play/activity area and the bathroom, and LPA toured all of these areas to conduct a health and safety inspection. There are no areas of the child care room that are off limits. There is a gate to prevent access to the licensee's home. The isolation area is a section of the child care room, away from other children in care. The child care room is neat and clean with heating and ventilation for the safety and comfort of children in care. The outdoor play area is the fenced yard, including the section near the child care room and the section near the licensee's home. There is an ample supply of toys and activities, which are age appropriate and in good condition. LPA did not observe any bodies of water, hazardous items or toxins accessible today. LPA observed a fully charged 2A10BC fire extinguisher. A telephone and first aid kit was observed. The facility was equipped with a working carbon monoxide detector and smoke detector which was found operable. There are no heaters accessible to children, and the unit does not have a fireplace. Per licensee, there are no firearms in the home. Inspection of the bathroom area was found in compliance with toilet paper and soap available to children. The licensees provides breakfast, lunch, and three snacks.

The Licensee’s Health and Safety training has been completed. Pediatric CPR and First Aid training has been completed and expires 8/2024.Licensee's and Licensee’s Assistant Mandated Reporter training is not current. Fire/disaster drill log is complete with the last drill logged 5/5/22. All required forms are posted and visible for public view in the child care room. LPA obtained the children’s files, assistants file, and facility roster. All adults have obtained a

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SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 05/24/2022 11:54 AM - It Cannot Be Edited


Created By: Indira Loza On 05/24/2022 at 10:56 AM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

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
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Based on interview and record review, the licensee did not comply with the section cited above as the LIcensee's assistant did not have proof of immunization for Pertussis and Measles. Upon interview of the Assistant, they stated they weren't sure if they had the immunizations for Pertussis and Measles; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Licensee will submit proof of immunization for Pertussis and Measles.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


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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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268
VISIT DATE: 05/24/2022
NARRATIVE
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criminal record clearance and all files were complete.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.



The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.
Licensee 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, 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

**************************************CONITNUE ON 809-C***************************************
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268
VISIT DATE: 05/24/2022
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this regulation is violated.

LPA discussed the safe sleep regulations with Licensee 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 Licensee 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.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted, report and appeal rights was reviewed with Licensee's daughter Sulma Zevallos.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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