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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155620046
Report Date: 12/19/2023
Date Signed: 12/19/2023 04:29:47 PM

Document Has Been Signed on 12/19/2023 04:29 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GOMEZ MARTINEZ, NATALIA FAMILY CHILD CAREFACILITY NUMBER:
155620046
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
12/19/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Natalia Gomez-MartinezTIME COMPLETED:
04:45 PM
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On 12/19/2023, Licensing Program Analyst (LPA) Jose Penate, conducted an unannounced Annual Required Inspection and was met by assistant, Juan Rivera (Spanish speaking). Upon arrival assistant was caring for 1 child in care and licensee was out running errands. Licensee arrived approx. 45mins after LPA's arrival to facility. Days and hours of operation are Mon-Fri 06:00 AM – 07:00 PM.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed rooms accessible for children to use are living room, dining room, bedroom 3, and hallway bathroom. “Off-limits” rooms are made inaccessible. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. During the inspection assistant was cleaning the kitchen (1:00PM) while child was in the living room, after cleaning the kitchen (1:05PM) the assistant left and proceeded down the hall and has left the child unsupervised until 1:25PM (20 minutes) minutes with his minor son providing care. LPA discussed with licensee that LPA is not counted as a care provider and that supervision shall be had by self or approved assistant.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort.

This is a single level home and there are no stairs. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is 661-458-7377.

Licensee is aware children shall not be left in parked vehicles. Capacity as specified on the license is being maintained.

Continued on LIC809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ MARTINEZ, NATALIA FAMILY CHILD CARE
FACILITY NUMBER: 155620046
VISIT DATE: 12/19/2023
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LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee and assistants Mandated Reporter Training has is valid and will expire on 10/24/2024. Assistants pediatric CPR/First Aid has not been completed, assistant was left with a child in care without having certification. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed 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-andresources/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. LPA discusses with licensee that 15 minutes infant sleep log must be completed at the time of checks and not at any other time.

Continued on LIC809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ MARTINEZ, NATALIA FAMILY CHILD CARE
FACILITY NUMBER: 155620046
VISIT DATE: 12/19/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview conducted and report was reviewed with licensee, Natalia Gomez Martinez. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA verified the RSO profile in FAS.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, deficiencies cited (See 809-D).

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2023 04:29 PM - It Cannot Be Edited


Created By: Jose Penate On 12/19/2023 at 03:04 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GOMEZ MARTINEZ, NATALIA FAMILY CHILD CARE
FACILITY NUMBER: 155620046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant left child unattended for approx 20 mins as described in LIC-809. Licensee was not present in the home and left child with assistant. This which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee will submit plan to not allow an unqualified assistant alone with children.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensees assistant was left alone with not having valid CPR certification. This which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee's assistant will complete CPR training by POC date. (1/31/2024)
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:Duane Matsubara
LICENSING EVALUATOR NAME:Jose Penate
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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