Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310833
Report Date: 10/09/2015
Date Signed 10/12/2015 08:22:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GOMEZ, FLORAFACILITY NUMBER:
304310833
ADMINISTRATOR:GOMEZ, FLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 533-9214
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:14CENSUS: 6DATE:
10/09/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Flora Gomez, LicenseeTIME COMPLETED:
04:15 PM
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The purpose of this visit was to conduct an Annual evaluation of the facility. Licensee was present as well as her assistant who were caring for 6 day care children of whom 4 is an infant. During visit LPA and licensee reviewed the home, and the facility files. LPA reviewed the facility staff records on 10/09/15, which indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The following was noted during visit that children were napping and licensee was getting ready to get them up from nap and was ready to provide them with a snack. Licensee provided her current Pediatric CPR and First Aid valid unit for both her and her assistant 01/2017. The home was toured inside and out, bathroom was checked for hazards, first kit available. Working fire extinguisher and fire alarms at the facility. See saw was located on cement pavement with plenty of cushion material.

LPA also reviewed with licensee the website flyer which may be used to down load forms and regulations. The website address http://www.ccld.ca.gov was given to licensee. LPA also reviewed with licensee all required forms, such as: updated regulations, forms packet, SIDS flyer, and Fingerprint SB933 Flyer, AB 633 fact sheet, PUB 394 (Notification of Parent’s Rights) poster and the LIC 995A (FCCH Notification of Parents’ Rights), each containing the database for Megan’s law and a copy of LIC 9224 (Acknowledgement of Receipt of Licensing Reports). Facility met title 22 regulations and no citations were issued.

Exit interview was conducted, copy of report issued and appeal rights provided.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2015
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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