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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700206
Report Date: 07/12/2022
Date Signed: 07/12/2022 01:59:42 PM

Document Has Been Signed on 07/12/2022 01:59 PM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GOMEZ VARGAS, IVONFACILITY NUMBER:
015700206
ADMINISTRATOR:GOMEZ VARGAS, IVONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 724-0693
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ivon Gomez VargasTIME COMPLETED:
02:15 PM
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On 7/12/2022 Licensing Program Analyst (LPA) Jaylena Miller, met with licensee Ivon Gomez Vargas for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for the inspection was the licensees fingerprint cleared and associated husband, and no daycare children present. Upon arrival LPA provided licensee a copy of form LIC 126. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 8:30am-5:30pm however is closed for the summer.

The home is a single story which consist of 4 bedroom, 2 bathrooms, living room, dining room/kitchen combination, backyard and garage. The home is neat and clean with heating and ventilation for safety and comfort. Children and parents enter through the side gate by the garage which leads to the back patio door.

The OFF LIMIT AREAS are 3 of the bedrooms, one located to the left side of the hallway towards the back of the home, the other two located on the right side and bathroom at end of hallway, kitchen, closets, garage and left side of backyard which will be inaccessible by closed and/or locked doors and visual supervision.

The ON LIMIT AREAS are dining room, family room to the right, first bedroom and bathroom to the left of the home, as well as part of the backyard. The ISOLATION AREA: Area in the on limits bedroom.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 2A-10-BC, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubes or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises.

The licensee completed the Health and Safety training 2/10/2017, CPR/First Aid is current and expires on 8/2022. The licensee is in complaint with the immunization laws and has completed the mandated reporter training on 11/23/2020. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 1/21/2022 but the facility is closed for the summer so the next drill will take place when children return. All required forms are posted and visible for public review.

Please LIC 809-C for continuance

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ VARGAS, IVON
FACILITY NUMBER: 015700206
VISIT DATE: 07/12/2022
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At 1:15 pm LPA Miller reviewed facility file. There is a current roster available for review and copy obtained.

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

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 [email protected]. 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.

Licensee 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, 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 licensee 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 licensee 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.

Licensee was reminded of the responsibility as a mandated reporter and the training's must be done once every two years as well as CPR/First Aid needs to be renewed every two years and must be EMSA approved. LPA also encouraged licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, as well as all forms can be downloaded. For licensing updates and Quarterly Child Care Distribution email, email [email protected] and ask to be added to the email list.

Please LIC 809-C for continuance

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GOMEZ VARGAS, IVON
FACILITY NUMBER: 015700206
VISIT DATE: 07/12/2022
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Effective August 1, 2003 California Law requires Child Care licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624 within 7 business days.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Ivon Gomez Vargas.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jaylena Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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