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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300957
Report Date: 05/09/2024
Date Signed: 06/17/2024 02:03:52 PM

Document Has Been Signed on 06/17/2024 02:03 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:DOMINGUEZ FAMILY CHILD CAREFACILITY NUMBER:
336300957
ADMINISTRATOR/
DIRECTOR:		DOMINGUEZ, SYLVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 834-5034
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Sylvia DominguezTIME VISIT/
INSPECTION COMPLETED:
10:48 AM
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On May 9, 2024, Licensing Program Analyst (LPA) Lorena Valenzuela conducted an unannounced inspection at Dominguez Family Child Care home and met with Licensee Sylvia Dominguez. The purpose of this inspection is to discuss information received during a review of an incident that occurred at the facility.
Based on information obtained by the Department, several children in the day care home were observed to be in the living room unattended sitting in a highchair and other children in awake in their play pen. In addition, Infant 1 (INF1), was observed alone in a sofa that is not age appropriate for children.
Based on interviews conducted and records review, the Department finds the facility did not comply with licensing regulations, due to not ensuring supervision of children in care at all times.
Facility is cited under Title 22, Section 102417(a) Operation of a Family Child Care Home.
A signed copy of this report, notice of site visit, and Appeal Rights, was provided to Sylvia Dominguez.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 06/17/2024 02:03 PM - It Cannot Be Edited


Created By: Lorena Valenzuela On 05/09/2024 at 09:47 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 336300957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
102417(a)

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102417 (a) Operation of a Family Child Care Home The licensee shall be present in the home and shall ensure that children in care are supervised at all times.
This requirement was not met as evidenced by:
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Licensee states will provide Department a written statement in regards to a supervision plan licensee will follow to ensure children are supervised at all times, by due date 05/17/24.
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Based on observation and interviews, the licensee did not ensure supervision of children in care due to several children being observed unattended while in care. This poses a potential risk to the health, safety and personal rights of children in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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