Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310833
Report Date: 12/19/2017
Date Signed 12/19/2017 05:08:14 PM

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:
12/19/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Flora GomezTIME COMPLETED:
05:15 PM
NARRATIVE
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The purpose of this visit was to conduct and Annual/Random inspection of the facility. Licensing Program Analyst (LPA) Nevarez-Martinez met with licensee. There are a total of 6 children in the home 3 are the licensee's grandchildren and 3 day care children. Age group present are as follows: 2 are infants, 2 toddlers, and 2 school age. Licensee stated that there are 3 adults in the home no one else. A review of adults living or working in the home on this date indicated individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA toured the home inside and outside. Children use the bonus room, kitchen, bathroom and back yard. All other areas of the home remain locked or with barriers to keep children from entering inaccessible areas. Licensee acknowledged that children may never enter these off-limit areas.

Children's bathroom was inspected located to right by the entry way of the home and is clear of hazards no eminent danger at time of visit. Lpa scanned areas used by the day care children for proper storage of all detergents, cleaning compounds, medications, perfumes, shampoos, toothpaste, and sharp pointed objects. There were age appropriate toys, equipment, and materials for children.

Licensee stated there are no weapons or guns in the home. Fire extinguisher, smoke detector and a carbon monoxide detector are present in the home. Licensee stated that they are not registered with any Foster Care agency. Licensee have current CPR and First Aid valid until 01/09/2018. Licensee met posting requirements. LPA also reviewed a sample of children's records and children's roster. Fire drill log reviewed. Licensee has the required immunization's of measles and pertussis but did not take the influenza she will send copies to the office by no later 01/02/2018 to place on file.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GOMEZ, FLORA
FACILITY NUMBER: 304310833
VISIT DATE: 12/19/2017
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. LPA provided information and form number for Individuals who are soon to be 18 years of age or older living in the home who must be fingerprinted cleared prior to presence in the facility. Live Scan tel# (800)315-4507, complete LIC9163. Criminal record clearances/exemption transfer requests (contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182) with copy of ID and LIC 508 to fax# (714)703-2831 prior to hiring staff. LPA reviewed requirements for posting Parent’s Rights poster with information regarding Megan's Law, Information regarding AB 633 and the requirements of documents to be provided to new parents. LPA advised of the new parent’s rights notification forms. LPA discussed supervision requirements, finger prints requirements, unusual incident report, children's files, ratio and capacity. The California Child Passenger Safety Law was discussed with licensee. LPA provided the licensee with the web sites www.ccld.ca.gov.The following was also discussed with licensee:
1) LPA discussed with licensee regarding Senate Bill 277 link: ttp://www.shotsforschool.org/laws/sb277faq/
2) Senate Bill 792 http://www.ccld.ca.gov/res/pdf/16APX-16.pdf.
3) A handout of A Child Care Provider's Guide to Safe Sleep discussed and provided to licensees..
4) LPA provided the link http://www.dss.cahwnet.gov/ord/entres/getinfo/pdf/ml_ccl1511.pdf
for the child care seat belt law and discussed with licensee during visit.
5) Chapter Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf . Exit interview conducted with applicant in Spanish and appeal rights procedure explained. Visit consultation was conducted in Spanish.
In the areas evaluated, no deficiencies were observed or cited per CA Code of Regulations, Title 22, and Division 12. The Notice of Site Visit was posted. Licensee were informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee were provided a copy of their appeal right (LIC 9058) and their signature on this form acknowledges receipt of these rights. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Maria NevarezTELEPHONE: (714) 703-2825
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2017
LIC809 (FAS) - (06/04)
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