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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844346
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:34:19 PM

Document Has Been Signed on 05/09/2023 02:34 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
334844346
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
05/09/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Maria GomezTIME COMPLETED:
02:55 PM
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On May 9, 2023 at 1:11 PM , Licensing Program Analyst (LPA) Ana Noble arrived at the facility to conduct a Case Management inspection due to the licensee applying to increase capacity to a large family childcare home and a review of the application was also included in the inspection. Present during this inspection was: Maria Gomez and 1 napping day-care child. The home is single story with 4 bedrooms, 2 bathrooms, with attached garage. Fire Clearance was approved by Fire Department on 5/1/2023.
At 1:30 PM, LPA toured the facility, inside and out with Maria Gomez and the following was observed and/or discussed:
· Normal days and hours of operation are: Monday through Friday 5 am - 7 pm
· Off-limit areas include: All bedrooms, right and left side of backyard and garage.
· The facility is licensed to have no more than 8 children as a small family child care home and is operating within the licensed capacity and appropriate ratios. There was only 1 child present during this inspection.
· Appropriate supervision provided during this inspection
· A working telephone is present, and the current phone number is on file
· A fully charged fire extinguisher was observed. A smoke detector and carbon monoxide detector were present and tested by the Licensee during this inspection.
· There is a fireplace in the home and is properly screened
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Weapons are present/stored according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· This is a one story home
· Clean, safe and age appropriate toys
· Current roster on file
· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted
· Documentation of fire and disaster drills on file – Last drill conducted on 01/17/2023.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844346
VISIT DATE: 05/09/2023
NARRATIVE
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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
Verification of control of property on file
· Children’s records are complete
· Employee’s records are complete,
· Mandated Reporter Training was completed by licensee 11/8/2022 and expires 11/8/2024.
· Pediatric CPR and First Aid Card expires on 11/8/2024, however training was not provided by an EMSA, American Red Cross or American Heart Association training provider.
· Health & Safety Certificate - completed on 09/23/2016
· Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov

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.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 334844346
VISIT DATE: 05/09/2023
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 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.
Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.

No deficiencies observed during time of inspection.

There are no corrections required, the application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. As agreed upon by the licensee, all corrections are due within 30 days. If not received within 30 days from the date of this report, the application may be withdrawn, and the license will remain a Small Family Child Care Home.

An exit interview was conducted, and this report was reviewed with the licensee Maria Gomez. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Ana Noble
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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