434416709-4-14-2021-07-CC-SYIP-C23NG9-20210414102646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416709
Report Date: 04/12/2021
Date Signed: 04/14/2021 10:26:58 AM

Document Has Been Signed on 04/14/2021 10:26 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	DOMINGUEZ GUZMAN, GUADALUPE		FACILITY NUMBER:	434416709
ADMINISTRATOR:	GUADALUPE DOMINGUEZ GUZMAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 767-1618
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 8	DATE:	04/12/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Guadalupe Dominguez Guzman		TIME COMPLETED:	03:22 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	Licensing Program Analyst (LPA) Samantha Yip conducted an announced Pre-Licensing inspection. Due to COVID-19 and shelter in place, a tele-inspection was conducted via Facetime. LPA met with Applicant Guadalupe Dominguez Guzman and explained the reason for the inspection. The purpose of this inspection is Applicant applied for a Large Family Child Care Home. Applicant has more than one year of experience that is required to apply for a Large Family Child Care Home. This address is currently licensed under Maria Dominguez #434414284. Present during today's inspection were Applicant, current Licensee, Maria Dominguez, Applicant's spouse, 6 day care children, and Applicant's 2 minor children. Applicant was advised that this Facility Evaluation Report (LIC 809) dated 04/12/2021 will be emailed to her. Applicant's reply to the email within 24 hours will serve as acknowledgement and the report was received. There is board to post all required posting, such as License, Emergency Disaster Plan, Notification of Parent's Right, and Earthquake Preparedness checklist. The hours of operation are Monday through Friday 7AM to 5PM. Applicant will be using her cell phone. Applicant plans on obtaining liability insurance. LPA explained that she needs to use the Affidavit Regarding Liability Insurance to inform parents if she does not have a daycare insurance. Applicant rents the home. Applicant also understands that she needs to be living in the home. Applicant guided LPA on a tour of the home via Facetime. A fire clearance for 14 children was granted on 03/03/2021. The off-limit areas of the home are the master bedroom, bedroom 1, bedroom 2, the garage, and the right side of the yard. There is a fireplace in the home, which is barricaded. The home was observed to be clean. Disinfectant, cleaning ---------------------CONTINUES ON 809 DATED 04/12/2021 PAGE 2-----------------------------

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ GUZMAN, GUADALUPE	FACILITY NUMBER: 434416709
	VISIT DATE: 04/12/2021

NARRATIVE

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-------------------CONTINUATION OF 809 DATED 04/12/2021 PAGE 1----------------------------

supplies, and other items that poses as an immediate risk to children were observed to inaccessible to children. There is sufficient amount of toys for children in care. There were no baby walkers observed during today's inspection. Applicant understands that baby walkers are not allowed. There is fully charged fire extinguisher, functioning smoke detector, and carbon monoxide detector. LPA reminded Applicant that fire disaster drills need to be completed every 6 months and documented. Applicant stated that there are no weapons, such as firearms, stored in the home. Applicant also has two dog. Applicant has a record of vaccines for her dogs on file.

Applicant plans on using the backyard, which is fenced. There is a play structure in the backyard, which is anchored to the ground. There is sufficient amount of toys for children. There were no bodies of water observed during today's inspection.

Applicant does plan on transporting children and understands that children cannot be left alone and unattended in parked vehicles. Applicant also understands that any assistant transporting children need to have a valid CPR/1st Aid. The form of disciple Applicant plans on using is the thinking chair. Applicant understands that children's personal rights should not be violated; including no corporal punishment.

Applicant does not plan on providing Incidental Medical Services (IMS). When any IMS is provided, a 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)/ (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.

Applicant does have a valid CPR/1st Aid, which expires on 12/01/2022. Applicant's Preventive Health and Safety, immunization records for measles, pertussis, and influenza,

---------------------CONTINUES ON 809 DATED 04/12/2021 PAGE 3----------------------------

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ GUZMAN, GUADALUPE	FACILITY NUMBER: 434416709
	VISIT DATE: 04/12/2021

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----------------CONTINUATION OF 809 DATED 04/12/2021 PAGE 2-------------------------

and Mandated Reporter Training certificate are on file. Applicant completed the Mandated Reporter Training on 03/09/2020. LPA reminded Applicant that the Mandated Reporter Training requires renewal every two years.

LPA emailed updated Family Child Care form packet with updated Licensing forms and reviewed it with the Applicant. Department website: www. ccld.ca.gov provided to the Applicant. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and healthy beverages in child care were discussed. LPA also discussed safe sleep information and forms required for children's file; along with any adults living in the home or employees.

LPA also emailed and discussed with Applicant COVID-19 resources.

The adults over the age of 18 are Applicant and her spouse. All adults have cleared criminal record, child abuse index clearance, and TB test results. LPA informed Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Applicant stated that she will submit the following:
- updated facility sketch of the yard
- letter from an previous employee: proof of 1 year experience

LPA conducted an exit interview with Applicant and LPA advised Applicant upon approval of Licensing Management, a license for a Large Family Child Care Home will be granted.

SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

LIC809 (FAS) - (06/04)

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