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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376301147
Report Date: 07/03/2025
Date Signed: 07/03/2025 03:27:24 PM

Document Has Been Signed on 07/03/2025 03:27 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 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:
07/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Mona DominguezTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) William Chancellor conducted an unannounced annual inspection for Dominguez Family Childcare (FCCH) on July 13, 2025, at 1:00 PM. LPA met with Licensee (LIC) Mona Dominguez, who granted entry and provided LPA a tour through the FCCH. During the inspection, LPA approved the facility for a capacity increase from eight (8) to fourteen (14) children. With an approved fire clearance on file dated June 4, 2025.

The facility operates Monday through Friday from 7:00AM- 6:00 PM, serving children 18 months- five years old. Certain areas listed as off-limits include: all three bedrooms in main residence, bathroom 1, detached garage/in-law studio, kitchen, laundry room and north side of backyard. Off-limit areas will include child safety locks and gates, making them inaccessible to children. Daycare children primarily pass from the entry to the back daycare room and utilize the covered patio and backyard. Facility is currently licensed as a small FCCH with a maximum capacity of eight (8) children and is operating within the capacity listed on the license. Upon arrival, no daycare children were present. LPA observed ample amounts of age-appropriate furniture and toys categorized by developmental themes under the covered patio. Additionally, LPA observed a newly installed artificial turf installed under the play houses in the back yard and a covered sand box.

A working cell phone is available, and the current phone number on file is correct. A fully charged fire extinguisher (2A:10BC) was observed in the laundry room. LPA observed an operational smoke detector mounted in the home hallway. Additionally, the home is equipped with a carbon monoxide alarm plugged in the home hallway. LPA confirmed operating child safety gate making the kitchen off-limits and inaccessible to daycare children. Kitchen knives were observed to be inaccessible to daycare children by a child safety latch drawer. LPA reminded licensee that all poisons and cleaning compounds deemed hazardous must be locked by a key. The license stated they understand that all off-limit areas are made inaccessible by child safety gates, doorknobs or lock and key, and must be operational during daycare hours.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/03/2025 03:27 PM - It Cannot Be Edited


Created By: William M Chancellor Jr. On 07/03/2025 at 02:25 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 376301147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above where CPR certificate expired May 9, 2025. Licensee provided care to daycare children from May 9- June 17, 2025. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee will email LPA proof of Child/Pediatric CPR certificate. Including American Red Cross, American Heart Association or EMSA approved vendor. CPR expire every two years and must be renewed prior to expiring.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two child files audited. Where child 3 (C3) and C4 were missing signatures on the consent for medical treatment (LIC 627). Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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Licensee will email LPA singed LIC 627 for C3 and C4. Licensee will email LPA a written decleration of understanding, ensuring all licensing forms are signed and appropriately filled out prior to children's presence in the FCCH.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Pauline Beschorner
NAME OF LICENSING PROGRAM MANAGER:
William M Chancellor Jr.
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


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: 07/03/2025
NARRATIVE
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Roster was requested an available for review and updated during inspection. LPA confirmed the required postings, including the Facility Sketch, Emergency Disaster Plan, License and Notification of Parent’s Rights, are displayed in the home entry way. Fire and disaster drill documentation was listed in the daycare entry, last drill recorded in May 2025. Licensee was reminded the home shall be kept clean and orderly.

Licensee stated they understand that all firearms, weapons, and ammunition must be locked separately and made inaccessible as per Title 22 Regulations.

LPA confirmed there are no pools, spas or other bodies of water present at the FCCH property at this time. Licensee Mona Dominguez stated they understand that all bodies of water including ponds, above 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 products must be emptied immediately after use and stored in an upright position.

Both children and employee records were audited during this inspection. Mandated Reporter Training is on file and valid through April 2026. Licensee Pediatric CPR and First Aid certification expired in May 2025. A deficiency will be cited. Resident and staff records were reviewed, and all adults requiring caregiver background checks have received the necessary clearances and exemptions.

CHILDREN'S RECORDS REQUIREMENTS:

• LIC 700 Identification and Emergency Information

• LIC 627 Consent for Emergency Medical Treatment

• LIC 282 Affidavit Regarding Liability Insurance

• LIC 9150 Parent Notification Additional Children in Care

• LIC 995A Notification of Parent’s Rights

• Immunization Record

• CDPH 286

• LIC 9227 Individual Sleep Plan- required for infants 12 months or younger

• 15 min sleep logs for infants 0-24 months. Including position, when under 12 months.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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: 07/03/2025
NARRATIVE
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FACILITY RECORDS:

• LIC 624B Unusual Incident/Injury Report

• LIC 9040 Child Care Facility Roster

• LIC 9052 Employee Rights

• Copy of your deed or lease/rental agreement

• Documentation of Fire and Disaster drills at least every six months

STAFF/VOLUNTEER FILES

• Fingerprint clearance and or exemption

• LIC 9108 Statement Acknowledging Requirement to Report Child Abuse

• Proof of current pediatric CPR and First Aid Certificates if transporting or licensee absence

• Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza

• TB clearance

• Mandated Reporter certificate – www.mandatedreporterca.com– must be renewed every two (2) years


Licensee Mona Dominguez was reminded that all adults 18 and over, living or working in the home, 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.

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. Licensee was reminded 15-sleep logs are required for all infants until the age of 24 months. LPA reminded licensee that sleep logs shall document position of the infant, under the age of 12 months, and include staff initials.

NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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: 07/03/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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: https://www.ada.gov/resources/child-care-centers/

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On-line Licensing forms & regulations for a Child Care Center can be obtained on the Department’s website: www.ccld.ca.gov. Additionally, there is a link to “Receive Important Updates” located on the right side of the page, immediately above 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. Unusual Incident Reports (UIR) must be called in within 24 hours and then electronically emailed or faxed within 7 business days at: unusualincidentreportsDO10@dss.ca.gov. Please refer to Title 22: 102416.2 Reporting Requirements- to reference mandatory reasons or incidents required to be self-reported to (CCL) in a timely manner.



On June 6, 2025, 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 addresses. 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.
NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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: 07/03/2025
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process for CARE tools, please send the email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

See LIC809-D for cited deficiencies. Additionally, advisory notes (LIC 9102) were provided to review regulations that were observed to be either in question or a potential risk for a future deficiency cited. Advisory Notes are provided with the intent to avoid issuing citations for violations that are technical in nature and do not present an immediate or potential health, safety or personal rights risk to those in care.

The application for a Large Family Child Care Home will be submitted for approval pending plan of corrections due July 11, 2025. A maximum capacity of 14 will be approved, requiring parent notification. Licensee Mona Dominguez stated they understand the following regulations and requirements:

  • acknowledged that when more than eight (8) children present, an assistant is required.
  • If an assistant is unavailable, the licensee must adhere to the small family childcare home ratio of no more than eight (8) children.
  • The licensee also confirmed their understanding that all adults aged 18 and older who assist, live, or volunteer in the home must undergo a fingerprint clearance before being present in the child care setting.
  • Additionally, the licensee acknowledged the requirement to be present for at least 80% of the time when children are in care.

An exit interview was conducted with licensee Mona Dominguez. The licensee received a copy of this report, Appeal Rights, and a Notice of Site Visit, which must be posted in a prominent location for 30 consecutive days.
NAME OF LICENSING PROGRAM MANAGER: Pauline Beschorner
NAME OF LICENSING PROGRAM ANALYST: William M Chancellor Jr.
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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