434416792-8-1-2022-07-CC-SYIP-CGVLE6-20220801084100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416792
Report Date: 07/29/2022
Date Signed: 08/01/2022 08:41:07 AM

Document Has Been Signed on 08/01/2022 08:41 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, ANA		FACILITY NUMBER:	434416792
ADMINISTRATOR:	A		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 234-6144
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	07/29/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Ana "Mellie" Dominguez		TIME COMPLETED:	12:25 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. LPA met with Applicant Ana "Mellie" Dominguez and explained the reason for the inspection. Applicant requested for a change of location. Applicant is currently licensed at 17135 Deport Street, Morgan Hill 95037. Present during today's inspection were Applicant, her spouse, and two assistants. Applicant understands that she needs to transfer fingerprints to her new facility number prior to them working. Applicant understands that she needs to live in the home. There is board to post required postings, such a notification of parent's rights and facility sketch. The hours of operation are Monday through Saturday 5:30AM to 5:30PM. Applicant rents the home. Applicant will be transferring her daycare insurance to her currently location. Applicant understands that parents need to sign the Affidavit Regarding Liability Insurance if she does not carry daycare insurance. There is working phone in the home. LPA toured the inside and outside of the home with Applicant. The off-limit areas of the home are all three bedroom, the bathroom next to the bedroom, kitchen, living room, and garage. There are fireplaces in the home, which are barricaded. Disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. There are toys for children. There were no baby walkers observed during today's inspection. Applicant understands that baby walkers and smoking is not permitted in the home. Applicant stated that there are no weapons, such as firearms, stored in the home. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. LPA reminded Applicant that fire/disaster drills need to be done every six months and documented. -----------------------------continues on 809 dated 07/29/2022 page 2----------------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

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

FACILITY NAME: DOMINGUEZ, ANA	FACILITY NUMBER: 434416792
	VISIT DATE: 07/29/2022

NARRATIVE

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-------------------continuation of 809 dated 07/29/2022 page 1---------------------------------

The backyard is used and is fenced. The off-limit areas outside of the home are the shed, dog run, and the left side of the yard. LPA observed that the fence at the back has panels that were loose, which has nails protruding. Applicant stated that she will either remove or nail it back it. LPA also observed that the wood on the shed is starting to rot, which could lead to injuries. There were also panels on the shed that were coming out. Applicant stated that she will nail the panels in. She also stated that her landlord will work on the shed on 07/30/2022. There were no bodies of water observed during today's inspection.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

------------------------continues on 809 dated 07/29/2022 page 3---------------------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

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, ANA	FACILITY NUMBER: 434416792
	VISIT DATE: 07/29/2022

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--------------------------continuation of 809 dated 07/29/2022 page 2---------------------------

Applicant does not transport, but understands that children cannot be left alone and unattended in parked vehicles.

Applicant has a valid CPR/1st Aid, which expires on 06/01/2024. Applicant completed the Mandated Reporter training on 11/01/2021. Applicant was reminded that the Mandated Reporter training requires renewal every two years. Her immunization records for measles, pertussis, and influenza are on file.

The adults 18 and over living in the home are Applicant, her spouse, and her son. Applicant's minor granddaughter also lives in the home. All adults have cleared criminal record, child abuse index, or exemption. TB test results for adults are on file. Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Applicant will submit the following:
- LIC 279 with original signature
- Health and Safety certificate
- lease agreement
- proof that nails on the fence were fixed
- proof that the shed was fixed

Exit interview conducted and report was reviewed with the Applicant Ana "Mellie" Dominguez. LPA advised Applicant upon approval of Licensing Management, a license for a Large Family Child Care Home will be granted upon completion of the following:
- proof that the nails on the fenced were fixed
- proof that panels on shed on fixed
- Health and Safety training was completed

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

LIC809 (FAS) - (06/04)

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