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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376301147
Report Date: 10/04/2024
Date Signed: 10/04/2024 10:10:17 AM

Document Has Been Signed on 10/04/2024 10:10 AM - 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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DOMINGUEZ FAMILY CHILD CAREFACILITY NUMBER:
376301147
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Mona DominguezTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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On October 4, 2024 at 8:30AM, Licensing Program Analyst (LPA) William Chancellor arrived at the facility to conduct a pre-licensing inspection. Present during this inspection were: Mona, Martha and Pete Dominguez. The property is on .45 acre, where the main residence has 3 bedrooms, 2 bathrooms and detached garage. The detached garage has been converted to an in-law studio with restroom. LPA toured the facility, inside and out with Mona Dominguez and the following was observed and/or discussed:

· Per Applicant, off-limit areas include: all three bedrooms in main residence, bathroom 1, detached garage/in-law studio, kitchen and north side of backyard. Off-limit areas will include child safety locks and gates, making them inaccessible to children.
· Normal hours of operation will be: Monday- Friday 6AM- 6PM.
· Smoke detectors and Carbon Monoxide detectors were tested by the applicant during this inspection and were in working order.
· The home has portable heating and air conditioning according to the season.
· The fire extinguisher is fully charged and meets standards established by the State Fire Marshal.
· All hazardous items were not observed to be inaccessible. Storage of poisons and toxins will be made inaccessible to children and locked under the kitchen sink. Sharp items including kitchen knives, are inaccessible and stored on the high kitchen counter top. Medicines will be stored in the kitchen cabinet with a child safety lock.
· First Aid Kit is in the daycare room and contains all required items.
· No guns or weapons are stored in the facility as of this date. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.
· Faux fireplace is properly screened.
· Clean, safe and age-appropriate toys were observed.
· LPA observed a working telephone.
· There were no toxic plants inside or outside the facility observed at this time.
· The outside activity area consists of: a covered patio with age appropriate furniture and toys. Behind the covered patio is a large, square shape backyard with age-appropriate slides and play equipment.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 376301147
VISIT DATE: 10/04/2024
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·There are no bodies of water observed on this date. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and 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 bodies of water described. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position when not in use.
· Applicant will not be transporting children.
· Verification of control of property is maintained by applicant.
· Facility Sketch and Emergency Disaster Plan will be posted.
· Pediatric CPR and First Aid Card expires May 2025.
· Mandated Reporter certificate expires August 2026.
· Preventive Health and Safety training, including nutrition and lead components will be completed.

Applicant was reminded all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The applicant provided proof of control of property.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA did observe the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC9149).

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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) or (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

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 376301147
VISIT DATE: 10/04/2024
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LPA discussed the safe sleep regulations with applicant 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 applicant 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.

On this date, 10/3/24, The California Attorney General – Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California’s Megan’s Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The following items were also reviewed with the applicant during inspection:
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months.
- Responsibilities of being a mandated reporter and updating training every 2 years.
- Personal rights of children in care, including no corporal punishment.
- Responsibility to know the Title 22 Regulations for anyone providing care and supervision.
- Capacity and Supervision requirements.
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility phone numbers must always be on file with the licensing office
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 376301147
VISIT DATE: 10/04/2024
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- Baby walkers, bouncy seats, exer-saucers, and other similar items are prohibited.
- Car seat law.
- Smoking is prohibited in the facility while providing child care or transporting children
- Once licensed, 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/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
- Applicant was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov
-The Applicant can submit fingerprint transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov
- Access to forms & Title 22 Regulations for Family Child Care Homes online at www.ccld.ca.gov
- The Duty Officer is available to answer questions Monday – Friday 8:00am to 5:00pm at: 951-782-4200.
Before licensure, the following needs to be corrected/completed:
1. Clear entry way of hazardous items.
2. Install rubber pads to corners of entertainment center.
3. Install rubber pads to corners of kitchen island.
4. Install child safety lock to bathroom sink cabinet, making it inaccessible to children.
5. Install child safety gate to the kitchen, making it off-limits to children.
6. Install backyard fence, making the north side of the backyard off-limits to children.
7. Clean walls of kitchen, hallway, and daycare restroom.
8. Install child safety locks to all three bedrooms and restroom 1, making them off-limits to children.
9. Complete preventive Health and Safety training. https://amerimedcpr.com/preventive-health-practices-with-nutrition/
10. Parent board will be posted with all necessary documents. Post Emergency Disaster Plan, Facility Sketch, Carseat Law Poster, Parents Rights Poster, Complaint Hotline poster and License.
11. Block Daycare TV cord.

Once all corrections have been verified, the application for a Small Family Child Care Home will be submitted for approval with a maximum capacity of 8 children. Applicant advised that all corrections are due within 30 days, or the application may be withdrawn.

Exit interview conducted and report was reviewed with the applicant Mona Dominguez.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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