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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408159
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:09:28 AM

Document Has Been Signed on 05/03/2023 11:09 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:GORGONIO, MARIAFACILITY NUMBER:
073408159
ADMINISTRATOR:GORGONIO, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 451-8829
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria GorgonioTIME COMPLETED:
11:30 AM
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On 05/03/2023 at 9:45 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced random inspection. LPA met with licensee, Maria Gorgonio, who granted inspection authority to tour the facility. Also present for the inspection were licensee’s assistant, Blanca Dolores and 8 children in care. Licensee states there are currently 10 children enrolled. Children’s files were reviewed. Assistant did not have a complete file (see 809D). Licensee indicated she was unaware that her assistant needed a file. LIC 857 and LIC 859 was provided to licensee during today's visit.

The children use the bathroom in the hallway, living room, bedroom #1, and patio. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is in the nap/bedroom. The LPA toured all areas used by children.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were no fireplaces or open face heaters accessible to children. There were safe toys, play equipment, and materials observed for children. There were no stairs. There is a working telephone in the home. Poisons, cleaning solutions, medications, and other items that pose a danger to children were accessible (see 809D). LPA observed a cleaning product under the sink in the bathroom. The licensee is advised that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 3A40BC fire extinguisher , working smoke alarm, and working carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on January 29, 2024 respectively.



LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission safety standards. Licensee was advised that infants shall not be swaddled while in care, loose articles and objects shall not be placed in the crib, and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was also advised that all infants up to 12 months of age should have the LIC 9227 form in their file. The LIC 9227 form was provided to the licensee during today's visit.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GORGONIO, MARIA
FACILITY NUMBER: 073408159
VISIT DATE: 05/03/2023
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AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com

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

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.

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 this regulation is violated.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Maria Gorgonio.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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Document Has Been Signed on 05/03/2023 11:09 AM - It Cannot Be Edited


Created By: Ashley Curry On 05/03/2023 at 10:42 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: GORGONIO, MARIA
FACILITY NUMBER: 073408159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by ensuring cleaning products were not underneat the sink in the bathroom and inaccessible to children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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By 05/10/2023 inform LPA of where the cleaning products will be stored in an area not accesible to children.
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 observation, interview, record review, the licensee did not comply with the section cited above bu ensuring the licensee's assistant has a TB test on file, which poses/posed a potential health, safety or personal rights risk to persons in care. Assistant did not have a file.
POC Due Date: 05/31/2023
Plan of Correction
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By 05/31/2023 will submit copies of all documents missing on LIC 859 form to LPA.
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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


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