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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842823
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:41:34 PM

Document Has Been Signed on 09/06/2024 03:41 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 CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
364842823
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 11CENSUS: 5DATE:
09/06/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Ruth GomezTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On the date and time listed, Licensing Program Analyst (LPA) Aman Lama arrived at the facility to conduct a Licensee Initiated- Case Management inspection. LPA came to inspect the home due to the licensee requesting to get licensed as a Large Family Child Care Home (FCCH). The FCCH received a fire clearance on 08-26-24. Upon arrival, LPA was met with licensee, Ruth Gomez. Licensee granted access to LPA who then toured the on-limits indoor and outdoor areas of the facility.
Normal days and hours of operation are listed as: Monday-Friday 6am-6pm.

OFF-LIMIT AREAS ARE LISTED AS FOLLOWS: 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-SEE LIC809D

· 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.

· 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 02-08-26

· Pediatric CPR and First Aid Card for licensee was updated and expires in 06-2026.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823
VISIT DATE: 09/06/2024
NARRATIVE
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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: 05/10/2024.

· 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 not yet received all required clearances or exemptions-SEE LIC9102.

· 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 -SEE LIC809D

-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.-SEE LIC809D

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823
VISIT DATE: 09/06/2024
NARRATIVE
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-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.

-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.



See LIC809-D for cited deficiencies. An office visit may be requested at a later time.

LPA Aman Lama informed licensee, Ruth Gomez that this report dated September 6, 2024 document(s) (3) Type A citation(s) which shall be posted for 30 consecutive days as there is(are) immediate risk(s) to the health, safety, or personal rights of children in care.


- 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: Gilbert Sena
LICENSING EVALUATOR NAME: Aman Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 09/23/2024 02:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/20/2024 11:17 AM


Created By: Aman Lama On 09/06/2024 at 02:10 PM
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/09/2024
Section Cited
CCR
102425(b)(3)

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***NO DEFICIENCY CITED***
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09/09/2024
Section Cited
CCR102425(5)

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INFANT SAFE SLEEP: (a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (6) Each infant's bedding shall be used for him/her only. Bedding that touches the infant’s skin shall be cleaned at least weekly or before use by another infant.
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Licensee is asked to watch the free safe sleep videos on our home website at: ccld.ca.gov and submit a written understanding of Safe Sleep Regulations no later than the POC due date.
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This was not met as evidenced by: LPA observed C1 in crib 1 upon arrival. When licensee removed C1 from the crib, the sheet was soiled in 3 different spots. After approximately 30 minutes, LPA observed C3 in the same crib. The sheets were not changed and the soiled spots were still
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visible. The bedding touching one infants skin and not being cleaned or changed before use by another infant poses an immediate health and safety risk to person in care.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Aman Lama
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/06/2024 03:41 PM - It Cannot Be Edited


Created By: Aman Lama On 09/06/2024 at 02:10 PM
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: GOMEZ FAMILY CHILD CARE
FACILITY NUMBER: 364842823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2024
Section Cited
CCR
102423(a)(2)

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PERSONAL RIGHTS: (a)Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to:
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Licensee is asked to watch the free safe sleep videos on our home website at: ccld.ca.gov and submit a written understanding of Safe Sleep Regulations no later than the POC due date.
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(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This was not met as evidenced by: LPA observed licensee put two of the smaller out of three infants in car seats. Although the straps were on and the infants were not sleeping, licensee kept them
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in the car seats for approximately 30 minutes. This poses an immediate health and safety risk to 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:Gilbert Sena
LICENSING EVALUATOR NAME:Aman Lama
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
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