343622657-12-15-2021-53-CC-JSMH-C9S35B-20211216165626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343622657
Report Date: 12/15/2021
Date Signed: 12/15/2021 03:52:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2021 and conducted by Evaluator Christopher Jackson

COMPLAINT CONTROL NUMBER: 53-CC-20210913161621

FACILITY NAME:	GOMEZ, SANDRA		FACILITY NUMBER:	343622657
ADMINISTRATOR:	GOMEZ, SANDRA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 670-8519
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	14	CENSUS: 7	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Sandra Gomez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Allegations:
Staff and children in facility are not wearing masks.
Licensee and individuals in the home not isolating when exhibiting COVID-like symptoms.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/15/2021 at 3:00 PM Licensing Program Analyst (LPA) Christopher Jackson conducted an unannounced complaint investigation inspection and met with Licensee, Sandra Gomez. The purpose was to discuss the above complaint allegations. It was alleged that staff and children in the facility are not wearing masks. During the course of the investigation, LPAs Jeevun Birk-Miller and Fabiola Diaz conducted interviews and obtained information pertaining to the allegation. The Licensee stated they were wearing masks before, but then there was confusion with the mandates. At this time, they were not wearing them. The Licensee was provided with updated guidelines and stated she will continue to wear masks. Conflicting statements were taken during the interviewe process. Licensee had been observed wearing a mask, as well as, some children. Although some statemets taken stated otherwise. Based on the interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A Technical Violation was assessed on the subsequent pages. An exit interview was conducted with the licensee.

Report Continues on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 53-CC-20210913161621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GOMEZ, SANDRA	FACILITY NUMBER: 343622657
	VISIT DATE: 12/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was alleged that the Licensee and individuals in the home are not isolating when exhibiting COVID-like symptoms. It was stated that an individual in the home had COVID-like symptoms and had been around children in care without a mask on. Licensee stated if a child is not feeling well, she will separate them and then call their parent. In an interview with the Licensee she stated if her own children are sick, they stay upstairs. Three of four parents interviewed stated they were unsure if children who aren’t feeling well were separated from the other children, but two of four believed or were told their child and/or other children waited in a separate area till they are picked up. Interviews conducted corroborated the individual was not isolating while having symptoms. Based on the information gathered during the investigation the Department found the licensee did not provide ensure an individual with symptoms was separated from the day care children, therefore, the allegation was substantiated. The following Type-B deficiency was cited on the 809-D page of this report. An exit interview was conducted with the licensee. Notice of Site Visit was provided and should remain posted for 30 days.

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 53-CC-20210913161621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GOMEZ, SANDRA	FACILITY NUMBER: 343622657
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2022 Section Cited CCR 102417(e)	1 2 3 4 5 6 7	102417 Operation of a Family Child Care Home (e) When a child shows signs of illness, he/she shall be separated from other children and the nature of the illness determined. If it is a communicable disease, he/she shall be separated from other children until the infectious stage is over.	1 2 3 4 5 6 7	The licensee said she would utilize other on limit areas of the home to allow for sick children to be separated from other individuals in care.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in separating an individual who had symptoms from children in care, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) 926-0269
LICENSING EVALUATOR NAME: Christopher Jackson	TELEPHONE: (916) 216-8837
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3