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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525408245
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:20:39 PM

Document Has Been Signed on 02/15/2023 02:20 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:DOMINGUEZ, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
525408245
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
02/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maria DominguezTIME COMPLETED:
02:30 PM
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A prelicensing inspection was conducted today at 12:50pm by Licensing Program Analyst (LPA), Mendez. LPA met with applicant Maria Dominguez The applicant is requesting a license for a capacity of 8. The facility will operate Monday-Friday, 7am to 5 pm. The residence is a 3 bedroom/2 bath single home. All adults in home are cleared and two minors currently living in the home.

The home and yard were toured, and the facility sketch was verified. The following areas will be off limits to children:2 bedrooms and garage. These areas have been made inaccessible by means of lock and door knob covers. Poisons are locked in garage. The home is equipped with a working smoke detector and fire extinguisher rated at least 2A10BC. The children will use the backyard as the outdoor play area. The backyard is completely fenced, the applicant understands that constant supervision must be provided while children are outside. There is no pool, spa, pond, fountain, or any other body of water on the premises.

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

Applicant representative 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.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: DOMINGUEZ, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 525408245
VISIT DATE: 02/15/2023
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LPA discussed the safe sleep regulations with applicant representative 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.

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.

The following items need to be completed prior to the granting of license:

1. Carbon monoxide detector.
2. Make knives inaccessible to children.

Exit interview conducted and report was reviewed with the applicant Maria Dominguez.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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