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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011849
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:42:33 PM


Document Has Been Signed on 07/18/2023 03:42 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
198011849
ADMINISTRATOR:GONZALEZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 232-4043
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY:14CENSUS: 6DATE:
07/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria Gonzalez, LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Susann Sanchez conducted a case management visit on 7/18/23 at 02:45PM. The purpose of the this visit is to obtain signatures for a previous virtual Noncompliance Conference. LPA observed Licensee son Paul Perez. Also present was Chris Cortez of Kaiser Permanante. Per Cortez, appointment was only 30 minutes and left at 2:52pm. LPA then observe Diego Perez. There were six children present. LPA reviewed the Noncompliance report with licensee and obtained signatures.

The following items were given to the licensee to update the file:
Facility Sketch- to obtain "off limit" areas and measurements: Due 08/01/23 Application: remove Ricardo Gonzalez - per guardian, individual was removed from the roster on 01/04/2012 Due by 08/01/23 Preventive Health & Safety Certificate Due 08/18/23.

The following was collected during today's inspection:

LIC 508: For Paul Perez and collected during today's inspection. LIC 9108: Statement Acknowledging Requirement to Report Child Abuse for all adults living in the home. Control of Property Photo IDs for all adults in the home and was collected during today's inspection. Current Immunizations: TB for Paul Perez & Diego Perez Measles, Pertussis, and Influenza for Licensee Copy of CPR & 1st Aid certificate Mandated Reporter training LIC 279: Current Children in Your Home and was collected during today's inspection.

Also collected was the LIC 421 Civil Penalty Assessment dated 07/06/23 No deficiencies were observed today 7/18/23. Exit interview was conducted with Maria Gonzalez, Licensee.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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