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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585408217
Report Date: 04/03/2023
Date Signed: 04/10/2023 09:29:57 AM

Document Has Been Signed on 04/10/2023 09:29 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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:GOMEZ, MARIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
585408217
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/03/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Maria GomezTIME COMPLETED:
01:45 PM
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A prelicensing inspection was conducted today at 12:05pm by Licensing Program Analyst (LPA), Laura Chavez. LPA met with applicant Maria Gomez. The applicant is requesting a license for a capacity of 8. The facility will operate Monday-Friday, 6:00am to 5:00pm. The residence is a 4 bedroom/2 bath single story home. There are 2 adults and 1 minor 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: garage, three bedrooms, including the master bathroom. These areas have been made inaccessible by means of locks and doorknob covers. The home is equipped with a working carbon monoxide detector, 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. There is no pool, spa, pond, fountain, or any other body of water on the premises. The applicant understands CCLD shall be notified prior to adding any body of water to the property.

LPA reviewed with applicant Maria Gomez 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.
Report continued: See LIC809-C
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: GOMEZ, MARIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 585408217
VISIT DATE: 04/03/2023
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Applicant 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.

LPA discussed the safe sleep regulations with applicant Maria Gomez 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 the 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. Proof of poisons having been locked.
2. Proof of making the garage off-limits to children.

Exit interview conducted and report was reviewed with applicant Maria Gomez.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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