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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421268
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:03:30 PM

Document Has Been Signed on 02/07/2024 03:03 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
OAKLAND CC RO, 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: 7DATE:
02/07/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Ena GomezTIME COMPLETED:
03:15 PM
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On 2/4/2024 at 10:02am, Licensing Program Analyst (LPA's) Dealia Frison and Briana Plumboy made an unannounced visit for the purpose of conducting a required annual inspection. LPA's were met by the licensee Ena Gomez.

Assisting Ena was neighbor A1. Present for the visit were three infants and four preschoolers. During the inspection licensees granddaughter and son in law arrived at the facility to assist with translation. At 2:40pm, licensee's assistant/ daughter Sulma Zevallos arrived at the inspection. The home was toured to conduct a health and safety inspection. The licensees primary language is Spanish. The facility operates Monday through Friday 8 AM-5 PM.

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's 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 are toys, learning materials, and activities, which are age appropriate and in good condition during today's inspection. LPA's did not observe any bodies of water, hazardous items or toxins accessible today. LPA's observed a fully charged 2A-10-BC fire extinguisher. The facility was equipped with a working carbon monoxide detector and smoke detector which were 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. The licensees provides breakfast, lunch, and three snacks daily to children in care.

The Licensee’s Health and Safety training has been completed. Pediatric CPR and First Aid training has be complete on 5/4/22 and expires 5/4/24. Licensee's and Licensee’s Assistant Sulma Zevallos have currentMandated Reporter training which expires June 2024. Fire/disaster drill log is complete with the last drill logged 11/22/23. All required forms are posted and visible for public view in the child care room. LPA's reviewed the children’s files, assistant file, and facility roster.

******************************CONTINUED ON 809-C*************************

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Dealia Frison
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268
VISIT DATE: 02/07/2024
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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's informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also reminded 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: Sherelle Johnson
LICENSING EVALUATOR NAME: Dealia Frison
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268
VISIT DATE: 02/07/2024
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LPA's 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's 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.

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 platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

During the exit interview, the Licensee Ena Gomez confirmed that there are no Registered Sex Offenders living in the facility.

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


For the Type A deficiency, a copy of this report and a copy of the Type A deficiency will be given to every enrolled family; a family member will sign an Acknowledgement of Receipt of Reports which is filed in each child's file for one year. Every new enrolled family from now to one year from now, 2/23/12, will also get a copy of this report and A Type deficiency and will sign the Acknowledgement of receipt.

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


See 809-D for deficiencies cited during today's inspection. Exit interview conducted, report and appeal rights was provided and reviewed with Licensee and translated to her by her granddaughter Angelina.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Dealia Frison
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2024 03:03 PM - It Cannot Be Edited


Created By: Dealia Frison On 02/07/2024 at 12:42 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GOMEZ, ENA
FACILITY NUMBER: 013421268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to A1 being present without finger print clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Licensee will ensure A1 is fingerprinted and cleared before volunteering or working at the facility.
TODAY A CIVIL PENALTY WILL BE ASSESSED OF $100.
Type A
Section Cited
CCR
102416.5(b)(2)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by having 3 infants and 4 preschool aged children in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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The Licensee states that she will abide by the ratio and capacity of her license, during all hours of operation. The Licensee states that she will unenroll one child or submit a schedule of when children are in care to LPA by 2/8/24, by email, fax or mail.
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Dealia Frison
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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