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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215924
Report Date: 08/02/2022
Date Signed: 08/02/2022 06:07:32 PM

Document Has Been Signed on 08/02/2022 06:07 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:DOMINGUEZ FAMILY CHILD CAREFACILITY NUMBER:
406215924
ADMINISTRATOR:MARIA ELENA DOMINGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 369-2127
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Maria Elena Donminguez TIME COMPLETED:
06:20 PM
NARRATIVE
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On 8/2/2022, at 3:05 PM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced Required Annual Inspection. Prior to entering the facility, LPA conducted COVID-19 pre-screening questionnaire and based on Licensee’s responses it was determined to be safe and free of any COVID-19 exposures. LPA met with Maria Dominguez, Licensee of the facility and explained the purpose of the visit. LPA observed nine (9) children being cared by Licensee. Licensee stated that the assistant had stepped out to run an errand.

The main day care areas are living room, dining room, kitchen, bathroom, outdoor yard and office playroom. Upon arrival LPA observed two small children sitting in vibrating chairs in the living room and a johnny jumper located in the office playroom. Off limit areas include bedrooms, laundry room and garage. LPA observe bedroom doors, laundry room door and garage door were not locked during this inspection.

LPA observed the day care area to be clean and orderly and provided plenty of ventilation for the children in care. In the kitchen, LPA observed raid, medication, and two knives in the counter of the kitchen. LPA observed most of the medication is stored in an elevated kitchen cabinet and on top of the refrigerator which is secure and beyond the reach of children. LPA observed knives are stored in a drawer that is locked. Cleaning compounds are stored under the kitchen sink that is locked and in the laundry room and garage that are not locked and accessible to children in care. Toys, furniture and equipment within the FCCH are age appropriate. The restroom used by children in care was observed to be clean. LPA observed hazard personal hygiene supplies, razors, toothpaste accessible to children. LPA notes that all hazardous items were removed from the kitchen and bathroom prior to LPA finishing the inspection.

Required forms are predominantly posted on the wall. LPA observed a combination smoke and carbon monoxide detector in the FCCH which was tested at 3:53 PM and found to be operable. Likewise, the home has a regulation fire extinguisher which was serviced on 2/8/22. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 406215924
VISIT DATE: 08/02/2022
NARRATIVE
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LPA reminded the Licensee to either service or purchase a regulation fire extinguisher annually. The home maintains working telephone services.

The backyard is made up of grass footing and is enclosed by wood fencing. The fence’s entry/exit gates are secure. LPA observed a trampoline in the outdoor yard. LPA notes no children were using the trampoline during today’s inspection. Per Licensee, trampoline is used by 3-4 children at a time. LPA advised Licensee of trampoline guidelines and left regulations that advise on trampoline usage. Toys and play equipment observed in backyard are age appropriate. No bodies of water are observed.

LPA reviewed Licensee and children's records. LPA reviewed files for all nine (9) children present during today’s inspection. All child files were found to have emergency card information. Per Licensee, she is not documenting 15 minute check for any infant because it is too much. LPA reviewed Licensee’s and Assistants documents and found, Licensee's Mandated Reporter training certification is valid until 3/10/23 and Licensee's Pediatric CPR and First Aid certification is valid until 4/30/23. LPA notes that assistant did not have Pediatric CPR and First-aid abd Mandated Reporter Training Certificate is only from 30 minute course. The Licensee informed LPA no firearms and ammunition are on site.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 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: htttp://www.ada.gov/childqanda.htm

LPA reviewed with Licensee the Safe Sleep Regulation. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided on line at www.ccld.ca.gov.

Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home and was advised to review Quarterly Updates and Provider Information Notices (PINs), Title 22 & Health & Safety Codes which can be accessed on-line athttps://www.cdss.ca.gov/inforesources/child-care-licensing

CONt 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 406215924
VISIT DATE: 08/02/2022
NARRATIVE
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A Notice of Site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee, Maria Dominguez.

Today, deficiency cited under Title 22 Division 12 Appeal rights given. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report LIC 809 and LIC 809 D.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/02/2022 06:07 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 08/02/2022 at 05:20 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 406215924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation, the licensee did not comply with the section cited above in that LPA observed two (2) infant vibrating chairs and one (1) johnny jumper accesssible to chidlren in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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Licensee agrees to stop using infant vibrating chairs and johnny jumper immediately. During this inspection, all items were moved to off-limits locations and Licensee stated she will get rid of all the items. Licensee agress to post poster of prohibited items by the parent area in the facility and email proof to LPA Pedroza at Francisco.Pedroza@dss.ca.gov
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in that there were nine (9) children present being supervised by one (1) adult which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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Licensee agrees to ensure there is always two (2) adults present in the facility providing care and supervision and will stop running errands during hours of operation to ensure capacity is maintained at all times. Licensee agress to write short summary and submit to LPA Pedroza at Francisco.Pedroza@dss.ca.gov
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:Maria Mueller
LICENSING EVALUATOR NAME:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


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Document Has Been Signed on 08/02/2022 06:07 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 08/02/2022 at 05:20 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: DOMINGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 406215924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(B)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.

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 Licensee chose to stop documenting 15 mintue check becasue it was too much which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee agrees to start documenting 15 mintue check with all infants as of tomorrow. Licensee agrees to email LPA Francisco Pedroza at Francisco.Pedroza@dss.ca.gov proof of infant's 15 mintue checks
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Maria Mueller
LICENSING EVALUATOR NAME:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


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