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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157700089
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:57:28 PM

Document Has Been Signed on 12/18/2024 03:57 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
157700089
ADMINISTRATOR/
DIRECTOR:
ADRIANA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 557-8229
CITY:ARVINSTATE: CAZIP CODE:
93203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
12/18/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:13 PM
MET WITH:Stephanie Gallardo, AssistantTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On Wednesday, December 18, 2024, at 2:13 pm, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced case management for capacity increase to large license (14) and met with assistant Stephanie Gallardo who granted access and guided LPA Rivera on a tour of the facility. Licensee is also requesting to utilize the accessory dwelling unit (ADU) as the primary area for child care. Fire clearance approved to utilize the ADU on 10/21/2024.

Family members residing in the home and assistant are background cleared. LPA observed 5 preschool children present. LPA observed facility to be within ratio. Operating hours are Monday to Friday from 5:00 a.m. to 6:00 p.m. and care for children ages 0 to 13 years old. Annual fee is current.

This facility is a one-story home that consists of 4 bedrooms, 2 bathrooms, kitchen, living room, dining room, attached ADU and backyard.

Areas off limits to children include- main premises- which includes all 4 bedrooms, kitchen, 2 bathrooms, living room, dining room and backyard.

Areas accessible to children include- 2 rooms and bathroom located in the ADU.

LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone and landline). For ventilation, LPA Rivera observed 2 mini split AC/heater units. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did not observe a fireplace nor a wall heater. LPA observed 1 crib and 1 play pen and observed to be free from bumper pads, blankets, pillows and hanging items.

LPA Rivera observed cleaning compounds items, stored in the main premises underneath the kitchen sink, and observed a gate barrier between the kitchen and dining area, making it inaccessible for children to enter. LPA observed the knives and sharp objects stored inside the kitchen drawer with a childproof lock making it inaccessible for children to open.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 12/18/2024
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In the ADU, LPA observed a gate barrier between the kitchen and playroom to prevent children entry to the kitchen. LPA observed the kitchen cabinets and drawers to have childproof locks. LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded assistant any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

For water drinking, assistant stated licensee provides filtered water, meals, and snacks. LPA informed assistant that any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.

LPA Rivera asked the if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee adult son stated has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, weapons, nor bodies of water. The assistant was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.



LPA Rivera observed the required 2A10BC fire extinguisher located in the ADU and the valve on the green area indicating fully charged and serviced on 4/19/2024. LPA observed a dual carbon monoxide detector and smoke alarm located in the ADU. Assistant tested the dual carbon monoxide and smoke alarm. LPA Rivera heard the sound and it is operable. For ill isolation, assistant stated licensee will be utilizing a corner of the daycare room. LPA observed the last emergency drill conducted on 5/10/24. LPA reminded assistant emergency drills are to be conducted every 6 months.

Per assistant the outdoor space is not utilized for outdoor playtime.

LPA Rivera observed licensee Adriana Gomez Emergency Medical Services Authority (EMSA) Pediatric First Aid/ CPR certification dated 3/42023 and Health and Safety certification dated 2/16/2023, and licensee has proof of immunization against Pertussis, MMR, and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter training dated 2/27/2023. LPA observed assistant Stephanie American Red Cross Pediatric First Aid/CPR dated 8/14/2024, child abuse mandated reporting certificate dated 8/24/2024 and proof of immunizations against Pertussis, MMR, and Influenza.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 12/18/2024
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LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, and Pub 394 Notification of Parents Rights and roster.

The following was also discussed with the assistant:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee 80/20 a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 12/18/2024
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8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.



12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: 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. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 157700089
VISIT DATE: 12/18/2024
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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.

Assistant Stephanie 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 the safe sleep regulations with assistant Stephane 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 assistant Stephanie 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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/.

Assistant Stephanie 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.

No deficiencies given during this inspection and approval for large license and ADU has been granted. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the assistant Stephanie Gallardo.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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