Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393609121
Report Date: 04/05/2017
Date Signed 04/05/2017 09:51:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:DOMINGUEZ, ANNETTEFACILITY NUMBER:
393609121
ADMINISTRATOR:DOMINGUEZ, ANNETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 830-0528
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:14CENSUS: 4DATE:
04/05/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Annette DominguezTIME COMPLETED:
10:00 AM
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LPA LeGuie met with licensee Annette Dominguez for a 3 year required visit. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety evaluation was conducted in all areas accessible to children. Adequate supervision was observed. Off-limits areas include the upper level of the home, laundry room and garage. The pool in the backyard is fenced with a self latching gate as required per Title 22 regulations. A pool fencing waiver is on file for pool alarms on all windows accessible to pool area. LPA observed a working phone, 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons in the home. No children were observed in parked cars. Toxic and hazardous items are inaccessible to children. Safe toys and comfortable accommodations were observed. The fireplace/stairs in the home were appropriately barricaded to prevent access by children. Outdoor play space is fenced.

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. Staff and children's records were reviewed. Preventative health training, current pediatric CPR and first aid certification was verified and expires 1/2018. A current roster and disaster drill log are being maintained. Updated immunization requirements were reviewed.

This facility evaluation report was reviewed and discussed with the licensee. A notice of site visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of 3 years for public review upon request. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of this form. In the areas that were evaluated, no deficiencies were observed at the time of the visit.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Eunique LeGuieTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2017
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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