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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004590
Report Date: 08/22/2022
Date Signed: 08/22/2022 10:09:06 AM

Document Has Been Signed on 08/22/2022 10:09 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOMEZ, KARLAFACILITY NUMBER:
414004590
ADMINISTRATOR:GOMEZ, KARLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 771-7468
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Karla GomezTIME COMPLETED:
10:30 AM
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On August 22, 2022 at approximately 8:20am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Karla Gomez, and explained the purpose of the inspection. Present in the home were licensee and 4 enrolled children (4 infants). Licensee is operating within capacity limits and ratios during LPA's visit on this date. All adults living in the home have a fingerprint clearance on file.

Hours of operation are Monday to Friday from 8:00am to 5:00pm. Licensee lives in the home with their spouse. The home includes 3 bedrooms, 2 bathrooms, living room, kitchen/dining area, backyard, front yard, and garage. The DAY CARE AREAS are bedroom #1 (napping room only), bedroom #2, bathroom #1 (located next to kitchen), living room, kitchen/dining area (pass-by only), backyard, front yard and garage. The OFF LIMIT AREAS are bedroom #3 and bathroom #2. All off limit areas are properly barricaded with locked doors. All individuals entering the home enter through the gate located on the side of the house.

At approximately 8:45am, LPA inspected day care areas for health and safety hazards. LPA observed home to be clean, in good repair with proper temperature and ventilation. All cleaning supplies, poisons, and other chemicals were inaccessible to children, in home's high shelves or locked behind child safety cabinets. Home is equipped with a smoke and carbon monoxide detector, fully charged fire extinguisher and fire alarm system. Per licensee, there are no weapons or firearms in the home.

Entire backyard is enclosed with an at least 5ft high fence. LPA did not observe home to have any pools, spas or bodies of water on the property. The backyard is equipped with appropriate outdoor toys and equipment that were in good working condition.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOMEZ, KARLA
FACILITY NUMBER: 414004590
VISIT DATE: 08/22/2022
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LPA reviewed four children's records which were complete. Children's records have a record of emergency identification on file. Licensee's CPR is current and will expire 11/2023. Licensee's Mandated Reporter certificate is current and will expire 02/2024.

Emergency drills are conducted at least once every six months and are properly logged and documented. Last emergency disaster drill was conducted 08/03/2022. Licensee also maintains safe sleep logs and documentation for each napping infant. Safe sleep logs document 15 minute time checks of when napping infant was last checked on as well as napping infant's sleeping position.

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: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email 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.

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.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOMEZ, KARLA
FACILITY NUMBER: 414004590
VISIT DATE: 08/22/2022
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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.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Karla Gomez.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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