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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842823
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:46:29 PM

Document Has Been Signed on 02/21/2024 12:46 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
364842823
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Ruth GomezTIME COMPLETED:
01:00 PM
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On date and time listed, Licensing Program Analyst (LPA) Aman Sharma arrived at the facility to conduct a required annual inspection. Upon arrival, LPA was met with licensee, Ruth Gomez. Licensee granted access to LPA who then toured the facility, both inside and outside.

Normal days and hours of operation are: Monday-Friday 6:00am-6:00pm
OFF LIMIT AREAS INCLUDE: Bedrooms 1 and 3, laundry room and backyard. The children use the front yard for outdoor playing space, which is fenced off and in compliance with Title 22 Regulations.
· The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision was being provided during this inspection.

· A working telephone is present and current phone number is on file.

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector were all in working order.

· Hazardous items and toxins were inaccessible to daycare children-SEE LIC9102

· No guns/weapons currently kept in the home. All guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.

· Verification of control of property is on file.

· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster were posted in the home.

· Mandated Reporter Training certificate for licensee is current and expires on 04-24

· Pediatric CPR and First Aid Card for licensee was updated and expires in 06-2024.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823
VISIT DATE: 02/21/2024
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· Health & Safety Certificate has been completed by licensee and is on file.

· Bodies of water were not observed on property 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, which are in compliance at this time. 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.

· Clean, safe and age appropriate toys were available to the daycare children.

· Roster was made available during today’s inspection.

· Documentation of last fire/disaster drill was conducted: 11/03/2023.

· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Children’s records, including infant files were complete during today’s inspection.

· Resident and/or staff records reviewed indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations862@dss.ca.gov

- LPA reminded licensee of the safe sleep regulations and discussed the Child Care Licensing Safe Sleep webpage as an additional resource at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

-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.

-Although licensee is not currently administering medications, Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823
VISIT DATE: 02/21/2024
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-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.htm

- 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: 951-782-4200.

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

Exit interview conducted and report was reviewed with the licensee, Ruth Gomez.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/0202
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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