<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157700089
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:37:38 AM

Document Has Been Signed on 05/03/2023 11:37 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
157700089
ADMINISTRATOR:ADRIANA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 557-8229
CITY:ARVINSTATE: CAZIP CODE:
93203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Adriana Gomez TIME COMPLETED:
11:40 AM
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
On 05/03/23 Licensing Program Analyst (LPA) Beneroso conducted a Pre-licensing Inspection with Applicant Adriana Gomez who guided LPA on a tour of the facility.

This is a one story house with 4 bedrooms, 2 bathroom, living room, kitchen, laundry room area and garage. Family members residing in the home include 3 adults (Applicant, Applicant’s husband and adult son) and 2 minor children.

The facility will operate Monday through Saturday from 5AM-5PM for less than 24 hours and with a license capacity of 14 children. LPA went over the child care ratios for a large family home with applicants, and provided applicants with a copy.

Main care will be provided in the living room area. Children will utilize bedroom #1 for nap time. Children will eat in the dining room area. Per applicants, they will be cooking for the day care children. The day care children will utilize the hallway bathroom on the left-hand side. Children will not use the backyard or front yard for outdoor play time. The front yard, backyard, bedrooms 2-4, bathroom #2, laundry room, and garage area are off limits to the day care children.

There are no pools or bodies of water on the premises.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Barbara Beneroso
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)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 05/03/2023
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
LPA observed day care area to be clean and orderly, central air and heating, age appropriate toys and play equipment, working smoke detector and carbon monoxide detector. There is a fire place that is properly barricaded by a baby gate.

LPA observed a clean, safe and operable toilet and faucet. LPA reminded applicant the children's bathroom must be free of shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover.

LPA observe a fully charge 3A40BC fire extinguisher during the inspection located in the day care area. First aid kit is stored in a storage closet with a door safety knob. LPA observed medications in the upper kitchen cabinet inaccessible to day care children in care.

Applicant made poisons and cleaning items inaccessible to children the kitchen in a lower cabinet made inaccessible by a baby gate and with safety latches on doors.

Kitchen: LPA observed the kitchen area to be free of hazards. Applicants safety latched the kitchen drawers and kitchen cabinets. The following are inaccessible: Sharp items are stored in a latched kitchen drawer inaccessible to children in care. LPA observed the refrigerator and freezer to be clean. LPA discuss with applicant food shall be properly stored or refrigerated in container that are labeled with child’s name when supplied by parent. Applicants do not have a food program at this time but will be joining a food program in the future.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Barbara Beneroso
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
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 05/03/2023
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
LPA toured the backyard and observed it to be all fenced in with cement block. Children will not have access to the back yard. LPA observed patio door to have safety latch to make it the backyard inaccessible to children. There are no pets in the home. Per licensee, the are no firearms in the home and no one smokes in the home.

Applicants were 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.

Documents Provided and or Discussed: The following were provided to comply with Title 22 requirements: Fire Drill Log, roster, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), water lead poster, required postings and list of CCLD forms required for child file each child in care (LIC 311D). Applicants stated currently does not have childcare insurance. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

Applicants were advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident to the department. Applicants were informed all suspected Child Abuse should be reported to the Child Abuse Hot-line at 1-800-540-4000. The above incident should be reported on the form LIC624B per the regulation. The form should be email to unusualincidentreport@dss.ca.gov

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Barbara Beneroso
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
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 05/03/2023
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
Advisory/Other: LPA observed a first Aid kit with emergency supplies and a thermometer in the kitchen area. Applicant First Aid/CPR are current. Preventative Health & Safety training is completed. Electrical outlets are inaccessible to children. Children will nap on cots in bedroom #1. Applicant aware no infant shall be swaddled, and car seat shall not be used for sleeping. Applicant is aware to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the infant’s status. Applicant should refer to regulation 102425(J) for documentation requirement. If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, the provider shall return the infant to their back for sleeping.

LPA discussed the safe sleep regulations with applicant, including Safe Sleep PIN 20-24-CCP 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 applicant 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.

Applicants informed smoking is prohibited, applicant stated no one smokes in the home, LPA discussed Health Section 1596.846(b) and (c)–102417 (g)(10) and provided applicant with a visual copy of prohibited items. LPA did not observe prohibited items during the inspection. Per applicant, no firearms are present in the home. Applicant were informed their cell phone shall be available and charged at all times during daycare hours.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Barbara Beneroso
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
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 05/03/2023
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
Incidental Medical Services (IMS) policy was discussed, informing applicant when any IMS is provided, a plan for providing IMS must be submitted to the Department prior to providing care to a child that need IMS. The plan shall state the type of IMS the facility will be offering, stating the person providing care has been trained to provide the named IMS. The plan will also provide the steps that will be taken when IMS is provided to a child.

The following information regarding ADA was discuss and the following information 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

Based on LPA's observations, the facility is now in compliance with Tittle 22 Regulations and is ready for licensure effective 02/27/23

Exit interview conducted copy of this report was provided to applicants along with notice of site visit.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Barbara Beneroso
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
LIC809 (FAS) - (06/04)
Page: 4 of 5