<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416792
Report Date: 03/18/2025
Date Signed: 03/18/2025 12:59:39 PM

Document Has Been Signed on 03/18/2025 12:59 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/
DIRECTOR:		AFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 234-6144
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 20CENSUS: 10DATE:
03/18/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Dominguez, AnaTIME VISIT/
INSPECTION COMPLETED:
01:10 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) Liridon Fici-Doni and Associate Government Program Analyst (AGPA) Joe Macias arrived unannounced to conduct a 1-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 5:30 AM to 06:00 PM. Licensee stated that the licensee, her two sons, and their partners are the adults residing in the home. Upon entrance, LPA observed three (3) staff and ten (10) children in care during inspection. Licensee's certifications for CPR and First Aid is current and will expire on 1/1/2026.



LPA and AGPA 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 six (6) 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 2/18/2025.

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 and AGPA observed a shed in the back yard with no knob and has a lock that inaccessible to children in care.


Page 1 of 4.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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 6
Document Has Been Signed on 03/18/2025 12:59 PM - It Cannot Be Edited


Created By: Liridon Fici On 03/18/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ, ANA
FACILITY NUMBER: 434416792

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not maintaining S2's mandate reporting certificate in the day care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
1
2
3
4
Licensee agreed to review and compose a self-certification letter on section 102417(g)- Operation of A Child Care Home and to sign, date, and submit to CCL by POC due date.

Deficiency cleared; Licensee removed items and locked them away.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/18/2025 12:59 PM - It Cannot Be Edited


Created By: Liridon Fici On 03/18/2025 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOMINGUEZ, ANA
FACILITY NUMBER: 434416792

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not maintaining mandate reporting certificate for Staff 2 (S2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
1
2
3
4
Licensee agreed to have S2 complete her mandate reporting certificate and to submit proof of completion to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 03/18/2025
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
LPA observed a fully charged 2A10BC fire extinguisher that is current, 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, are stored inaccessible to children.

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 for any updates, PINS, and regulations.

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 3/6/24. 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 3/17/2025 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.

Page 2 of 4

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

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 03/18/2025
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
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.

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.


Page 3 of 4
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 03/18/2025
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
The following deficiencies was observed during inspection:

1. LPA observed a pair of scissors on the BBQ grill and a small screw driver located in the back yard on a table.

2. LPA observed missing mandated reporting training for Staff 3 (S3).

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.



Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

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

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


Page 4 of 4
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6