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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009603
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:08:36 PM

Document Has Been Signed on 03/16/2022 03:08 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GOMEZ, GENEVA FCCHFACILITY NUMBER:
483009603
ADMINISTRATOR:GOMEZ, GENEVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 980-8137
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Geneva GomezTIME COMPLETED:
03:20 PM
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. A review of staff records on 03/16/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently three adults living in the home. 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. The facility did not have any standing waiver(s).

During today’s inspection the home and grounds were toured. The Licensee (LS) and two staff (S1 & S2) were supervising eight children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:30AM to 5:30PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms and one bathroom and the garage, and were made inaccessible by children's safety gates and plastic door knob covers.

The home was clean and orderly and was at a comfortable indoor temperature. The fireplace in the living room was securely screened. There were safe toys and equipment available for children. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification expire on 01/08/24. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. LPA did no observe any poison(s). (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOMEZ, GENEVA FCCH
FACILITY NUMBER: 483009603
VISIT DATE: 03/16/2022
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LPA reviewed three staff (S1-S2 & LS) records at 1:05pm which contained Criminal Record Clearance Statements (LIC 508), staff required Immunization Records (IR), Evidence of negative TB clearance and current AB 1207 Mandated Reporter Training certificates. LPA reviewed eight children's (C1-C8) record at 1:28pm which contained Immunization Record (IR), LIC 627, signed parent’s Rights (LIC 995), IR was transcribed onto the blue CDPH 286, identification and emergency information (LIC 700), LIC 282; and Infant Sleep Plan (LIC 9227) for four infants in care. During today's inspection, LPA observed four play yards for four children under 24 months, and the Licensee furnished proof of 15 minutes checks were being conducted for napping infants. The facility conducted an emergency drill within the past six months and the last drill was conducted on 02/22/22. The facility roster of the children in care was reviewed and appeared to be complete. Licensee stated there were no firearm(s) and/or other dangerous weapons stored in the home. The front yard is used as the children’s outdoor play space and it was fully fenced. There were no pools or other bodies of water observed in the yard. The facility is not providing Incidental Medical Services (IMS) to children in care.

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

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-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.



A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee. The were no violation(s) of the California Code of Regulations, Title 22; Division 12, observed. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOMEZ, GENEVA FCCH
FACILITY NUMBER: 483009603
VISIT DATE: 03/16/2022
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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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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