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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243809958
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:41:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GOMEZ, BERTHA FCCFACILITY NUMBER:
243809958
ADMINISTRATOR:GOMEZ, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 382-2612
CITY:PLANADASTATE: CAZIP CODE:
95365
CAPACITY:14CENSUS: 6DATE:
10/16/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bertha Gomez - LicenseeTIME COMPLETED:
11:00 AM
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On 10/16/2019 at 10:00am Licensing Program Analysts (LPAs) Joseph Pacheco and Jose Penate arrived at the family day care home to conduct an unannounced Case Management inspection. LPAs met with Spanish speaking Licensee, Bertha Gomez, toured the facility and a census was taken.

LPAs discussed with Licensee best practices for providing supervision to children in care. LPAs also discussed reporting requirements with Licensee regarding unusual incidents.

Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiency was cited during today's visit.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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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