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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622657
Report Date: 07/15/2019
Date Signed: 08/08/2019 04:33:43 PM

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:GOMEZ, SANDRAFACILITY NUMBER:
343622657
ADMINISTRATOR:GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 11DATE:
07/15/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Norma ZambranoTIME COMPLETED:
03:25 PM
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Licensing Program Analysts (LPAs) Marissa Soto and LPA Stacey Williams met with Licensee assistant Norma Zambrano for unannounced visit for the purpose of a room approval for on limits. LPA Soto and Williams toured all areas of the home that are accessible to children, today’s census included eleven children supervised by two assistants. Also present during today’s inspection was assistant Gabriela Aguirre Aguilar who has been finger print cleared through Community Care Licensing.


Off-limit areas include: Entire second floor, Garage, and South Side of the backyard. Licensee acknowledged that children may never enter these off-limit areas.

In the areas that were evaluated, no deficiencies were observed at the time of the visit. Kitchen and dinning room are approved effective today 07/15/2019.

Assistant Zambrano acknowledges that when there is no assistant present, facility will revert back to the small capacity. Zambrano acknowledges that children residing in the home under the age of 10 years shall be included in capacity.

Exit interview conducted. Notice of Site Visit posted.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Marissa SotoTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2019
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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