414004590-3-7-2024-05-CC-JGIL-D363U3-20240307173251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004590
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:32:59 PM

Document Has Been Signed on 03/07/2024 05:32 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	GOMEZ, KARLA		FACILITY NUMBER:	414004590
ADMINISTRATOR:	GOMEZ, KARLA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 771-7468
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 1	CENSUS: 1	DATE:	03/07/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Karla Gomez		TIME COMPLETED:	05:50 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On March 7th, 2024, at approximately 3:00 PM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPAs met with licensee, Karla Gomez, and explained the purpose of the inspection. Present during LPAs' visit included 1 infant. Licensee is a large license but is operating as a small within capacity limits and ratio.

Licensee lives in a single-level home with her spouse. All adults living in the home have fingerprint clearance on file. Hours of operation are Monday through Friday 8:30 AM to 5:00 PM and Fridays.

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 enter the home enter through the gate located on the side of the house.

LPA toured day care areas of home with licensee. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good working condition. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. LPA observed electrical outlets to be made inaccessible with furniture. Home is equipped with a fully charged fire extinguisher and multiple carbon monoxide detectors. Licensee also has a fire alarm by the front entrance. LPA tested carbon monoxide detector in room #1, which was observed to be working. LPA did not observe any hazardous materials accessible. Safety locks are installed in all cabinets of main day care room (bedroom #1). Licensee does have one child who is allergic to tofu and soy sauce. Allergies are posted in prominent place and an enclosed epi-pen is available to licensee. Per licensee, she provides all food for the children in her care.

Bathroom for children's use was observed to be in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. Per licensee, she has no children in care that need to use the bathroom. LPA did not observe any hazardous materials to be accessible to children in bathroom.

Continue Report on Page 2...

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOMEZ, KARLA	FACILITY NUMBER: 414004590
	VISIT DATE: 03/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued, Page 2...

LPA observed licensee to utilize a play pen for her one infant in child. The entire backyard is fully enclosed. Outdoor area is equipped with a variety of toys and materials. LPAs did not observe pools, spas or bodies of water.

LPA reviewed one child’s records which were complete. The child’s file has a record of emergency identification information and required immunization. LPA reviewed staff records for licensee which was complete. Licensee's CPR/FIrst Aid is current and will expire 07/2025. Licensee's Mandated Reporter training certification is also current and will expire 05/2027. Licensee also has required immunization available for review. Licensee has current Mandated Reporter training certification that will expire 7/2025.

Licensee has licensing documentation properly posted and available for review. Licensee also maintains a childcare roster that was made available for review. Emergency disaster drills are conducted at least once every six months. Last disaster drill was conducted January 2024. Per licensee, there are no weapons or firearms in the home.

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 or CARE tools, please send 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/inspection-process.

Licensee 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.

Continue Report on Page 3...

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOMEZ, KARLA	FACILITY NUMBER: 414004590
	VISIT DATE: 03/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued, Page 3...

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-andresources/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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are 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.

During the exit interview, the licensee, Karla Gomez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were issued today during LPA's visit.

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

Exit interview conducted and report was reviewed with the licensee, Karla Gomez.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3