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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021106
Report Date: 12/07/2022
Date Signed: 12/07/2022 03:13:35 PM

Document Has Been Signed on 12/07/2022 03:13 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GOMEZ & CRUZ FAMILY CHILD CAREFACILITY NUMBER:
198021106
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Gomez, ApplicantTIME COMPLETED:
03:30 PM
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 December 7, 2022 Licensing Program Analyst (LPA) Monique Ayala conducted an announced Prelicensing Inspection. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with applicant Maria Gomez to who guided LPA on a tour of the facility. Also living in the home is applicants/co-licensee spouse Jose Cruz and applicants 3 small dogs who are all up to date on vaccinations.

This is a single story home with 4 bedrooms, 2 bathrooms, living room, dinning room, kitchen, detached garage and fenced in rear yard. Days and hours of operation will be Monday to Saturday from 6am to 6pm.

Main care is provided: Living room, dinning room, kitchen, bedroom #2 (napping room) and #3 (isolation area), bathroom #1 and #2 and front half rear yard.

Off limit areas: Bedroom #1 and #4, detached garage, and back half of rear yard (where 3 dogs are located). The bedrooms, bathroom, detached garage and back half of rear yard are inaccessible by locked doors, applicant will keep all keys inaccessible to children in care.

The children and parents with enter through the front door for drop off and pick up.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GOMEZ & CRUZ FAMILY CHILD CARE
FACILITY NUMBER: 198021106
VISIT DATE: 12/07/2022
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
The infants will sleep in the in bedroom #2 where the napping room is located. Applicant has provided cribs for the infants and cots for the older children. The fenced outside play area is free from defects or dangerous conditions.

Per Applicant, there are no weapons or firearms on the premise. LPA did not observe any in the home. There are age-appropriate toys (blocks, dramatic play area, dolls, kitchen set). Age appropriate napping equipment (cots and cribs).

The required fire extinguisher (2A10BC) and smoke detector are in operable condition. The home has a Carbon Monoxide detector. Home has central AC and heat. CPR/First Aid expire 09/18/2024. The First Aid kit was observed and is complete.

The following was discussed with the Applicant:


Capacity requirements, Notification of Parent's Rights, Roster requirements (keep updated names and blue sheet), Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, Safe Sleep. The role and responsibilities of being a mandated reporter were reviewed. Applicant was advised on how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Applicant was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care. Applicant advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified. Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family child care home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GOMEZ & CRUZ FAMILY CHILD CARE
FACILITY NUMBER: 198021106
VISIT DATE: 12/07/2022
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
Requirements for fingerprint clearances and associations were discussed with the Applicant. Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the on the form LIC624B (Same day/ASAP or within next business day within normal business hours 8-5 and written report within 7 days). Pamphlet providing Information regarding, Seat Belt Safety and Notification of Parent's Rights poster (Monterey Park Regional Child Care Office) was provided. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. The information regarding new legislation with regards to exemptions and Parent’s Rights was also discussed.

Applicant was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent when a serious deficiency, Type A, is cited (LIC9224).

Applicant informed to review Quarterly updates/regulations for 2015-2019 on the department website: Summer 2015 - Incidental Medical Services information.



--Applicant was advised visit www.shotsforschool.org for Immunization information.
--Applicant was informed of responsibility to report suspected Child Abuse, 1-800-827-8724
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GOMEZ & CRUZ FAMILY CHILD CARE
FACILITY NUMBER: 198021106
VISIT DATE: 12/07/2022
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
--Family Child Care Providers (Disaster Planning information): https://ccld.family-child-care-providers/disaster-planning-and-fire-safety/https://ccld.family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Videos: https://ccld.childcarevideos.org
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

--Applicant was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.



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.html (Plan is on file or currently no plan on file).

LPA reviewed the Safe Sleep Regulation, LIC9227 and Sleeping Log with applicant.

LPA provided applicant with office number (323) 981-3350 for On Duty question or to report incident reports.

Applicant is ready for licensure.

An exit interview was conducted, and a copy of this report was provided to the applicant on this date.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4