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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543909506
Report Date: 08/24/2021
Date Signed: 08/25/2021 08:43:38 PM

Document Has Been Signed on 08/25/2021 08:43 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:DOMINGUEZ, ELODINA FAMILY CHILD CAREFACILITY NUMBER:
543909506
ADMINISTRATOR:DOMINGUEZ, ELODINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 627-1350
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Elodina Dominguez TIME COMPLETED:
01:00 PM
NARRATIVE
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On 8/24/2021, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced annual inspection and met with Licensee, Elodina Dominguez (Spanish/English speaking) and her Assistant Marisela Romero. A tour of the home was conducted, and a census was taken. Current facility sketch reviewed, and Licensee confirmed the living room (child care room), dining room, kitchen, hall bathroom, and the fenced backyard are used for providing care and are accessible to day care children. All other rooms are off-limits and are made inaccessible by use of spinner knobs and safety gates.
Medications and other hazardous items were inaccessible to children. LPA did not observe any poisons in the home. There was no fireplace. The fireplace located in the child care room was made inaccessible to children by a faux brick board and will not be used during day care hours. The fire extinguishers, smoke detectors, and carbon monoxide detector met Community Care Licensing (CCL) regulations. Heating/cooling and ventilation was sufficient for safety and comfort. There were no stairs in the home. Safe toys and play equipment were observed. Licensee had a working telephone and the above telephone number was verified. Adequate supervision was being provided during this inspection. Capacity as specified on the license was being maintained. Staff-child ratios were maintained.
There are currently no infants in care. LPA discussed Safe Sleep Regulations with Licensee, and provide a Safe Sleep information handout.
The outdoor play area in the backyard is fenced and there are no hazards to day care children. Licensee ensures that children in care are supervised at all times. There were no swimming pools, bodies of water, or firearms on the premises.
A sample of children’s records contained all emergency information specified by regulation. There were no excluded individuals present at this home. All adults who reside or work in the home had a criminal record clearance or exemption.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: DOMINGUEZ, ELODINA FAMILY CHILD CARE
FACILITY NUMBER: 543909506
VISIT DATE: 08/24/2021
NARRATIVE
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 A review of records indicated Licensee and all employees and/or volunteers have proof of required immunization (Pertussis/Measles/Influenza). Licensee's Mandated Reporter Training was completed on 8/6/2020. LPA discussed required Mandated Reporter Training to be completed by 9/7/2021 . Licensee was reminded the Mandated Reporter Training shall be renewed every two years following the date on which it was initially completed. Licensee's pediatric CPR and First Aid expires on 11/28/2019.
Incidental Medical Services (IMS) are not currently provided. Licensee is aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA information line at (800) 514-0301 (voice), (800) 514-0383 (TDD), and website link: https://www.ada.gov/childqanda.htm. http://www.ada.gov/childqanda.htm

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms, and Regulations.

Business hours are Monday through Friday 7:30 AM to 6:00 PM and other hours as arranged.

Per Title 22, Division 12, Chapter 3 of the California Code of Regulations, the following deficiencies were found:
A home fire drill has not been conducted since 7/18/2018.
Licensee and her Assistant's Mandated Reporter Training certification expired on 8/6/2020.

Licensee was provided a copy of the Facility Evaluation Report (LIC 809), Appeal Rights, and the Notice of Site Visit form (LIC 9213). The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2021 08:43 PM - It Cannot Be Edited


Created By: Theresa Marquez On 08/24/2021 at 11:48 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: DOMINGUEZ, ELODINA FAMILY CHILD CARE
FACILITY NUMBER: 543909506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
102417(g)(9)(A)(1)

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OPERATION OF A FAMILY CHILD CARE HOME - Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. This requirement is not met as evidenced by:
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Licensee stated she will conduct a fire drill on 8/25/2021 and submit evidence of proof to the Fresno CCL office by 8/27/2021.
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A record review of Fire Drill log. The last fire drill was conducted on 7/18/2018. This poses a potential risk to the health, safety and personal rights of the children in care.
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Type B
09/07/2021
Section Cited
HSC1569.8662(b)(1)

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MANDATED REPORTER TRAINING- On or before 3/30/2018, a person who, on 1/1/2018, is a licensed child 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 (MRT) every 2 years following the date on which
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Licensee and her Assistant will conduct the MRT by 9/7/2021 and submit proof of completed training to the Fresno CCL office by 9/7/2021.
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he or she completed the initial mandated reporter training. This requirement was not met by record review. MRT certificates for Licensee and her Assistant expired on 8/6/2020.
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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:Susie Fanning
LICENSING EVALUATOR NAME:Theresa Marquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


LIC809 (FAS) - (06/04)
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