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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416792
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:04:34 PM

Document Has Been Signed on 03/08/2024 12:04 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:DOMINGUEZ, ANAFACILITY NUMBER:
434416792
ADMINISTRATOR:AFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 234-6144
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/08/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dominguez, Mellie (Ana)TIME COMPLETED:
12:20 PM
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On 3/8//2024, at 9:45 AM, Licensing Program Analyst (LPA) Doni Fici arrived unannounced to conduct a Required 3-Year inspection and was greeted by Licensee, Dominguez, Mellie (Ana) and explained the purpose of the visit.

Days and hours of operation are Monday to Friday from 5:00 AM to 12:00 AM. Licensee stated that the licensee, her son, and her son-in-law are the adults residing in the home. Upon entrance, LPA observed three (3) staff and nine (9) children in care during inspection. Licensee's certifications for CPR and First Aid is current and will expire on 1/1/2026.



LPA toured the indoor and outside areas of the home with licensee during today's inspection. LPA obtained a copy of the Child Care Facility Roster during today's inspection, and it is current. LPA reviewed five (5) child's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. LPA review three (3) staff files and observed all forms/documentation's are current. LPA observed that last fire drill was documented on 2/14/2024.

The Licensee has a working cell phone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed there are not stairs in the home. Off limit areas in the home are the bedrooms, living room, main bathroom, kitchen, and garage. Licensee uses part of the back yard as a playground. Off limits areas to the outside of the house is the sides of the back yard.

LPA observed a fully charged 2A10BC fire extinguisher last time serviced on 8/1/2023, with working smoke and carbon monoxide detectors that are interconnected. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.
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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, ANA
FACILITY NUMBER: 434416792
VISIT DATE: 03/08/2024
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LPA observed Licensee has proof of immunization for pertussis, measles, and influenza in her file for herself according with the SB792.
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a helper must be present. The Licensee states that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA discussed the requirements of AB 633 with the Licensee. LPA also discussed "zero tolerance" related regulations with the Licensee. Licensee has completed the required "mandated reporter" training on 3/5/24. Licensee understands that all adults in contact with children are required to complete the training. LPA provided licensee with the website address for the training: www.mandatedreporterca.com. for additional information.

A review of staff records on 9/13/22 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOMINGUEZ, ANA
FACILITY NUMBER: 434416792
VISIT DATE: 03/08/2024
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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. Licensee currently has no kids that need IMS assistance. Licensee does not have any children that need Incidental Medical Services.

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.

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

No deficiencies cited during visit.

Exit interview conducted with licensee, and a copy of this report reviewed and provided.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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