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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911097
Report Date: 03/03/2023
Date Signed: 03/03/2023 10:50:04 AM

Document Has Been Signed on 03/03/2023 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GOMEZ, DORA FAMILY CHILD CAREFACILITY NUMBER:
543911097
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dora GomezTIME COMPLETED:
11:00 AM
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On 3/3/2023, Licensing Program Analyst (LPA) Theresa Marquez conducted an unannounced Required 1 year inspection and met with Licensee, Dora Gomez (Spanish speaking) A tour of the home was conducted. There were no children present during this inspection. Current facility sketch reviewed, and Licensee confirmed the living room, dining/kitchen area, and hall bathroom are used for providing care and are accessible to day care children. Hours of operation are Monday through Friday 5:00 AM to 5:00 PM.

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.
The outdoor play area in the backyard is fenced and there are no hazards to day care children. Licensee has 1 dog that is inaccessible to children. Licensee is aware of child safety around pets and accepts responsibility for any action taken by pets. There were no swimming pools, bodies of water, or firearms on the premises.
A review of records indicated Licensee has proof of required immunization and/or written declaration declining flu shot. Licensee's pediatric CPR and First Aid expires on 6/29/2024.

Licensee Gomez 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, 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. Continued on LIC809-C
SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GOMEZ, DORA FAMILY CHILD CARE
FACILITY NUMBER: 543911097
VISIT DATE: 03/03/2023
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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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations no deficiencies were observed today.

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.

An exit interview was conducted and report was reviewed with the Dora Gomez. A copy of the evaluation report, Appeal Rights and the Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Luisa Gavoutian
LICENSING EVALUATOR NAME: Theresa Marquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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