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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622657
Report Date: 01/26/2022
Date Signed: 01/26/2022 01:51:43 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
10/21/2021 and conducted by Evaluator Jeevun Birk
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20211021081752
FACILITY NAME:GOMEZ, SANDRAFACILITY NUMBER:
343622657
ADMINISTRATOR:GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 8DATE:
01/26/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Sandra GomezTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Personnel requirements were not met for staff working in home
Licensee uses highchair to restrain children in care
INVESTIGATION FINDINGS:
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On 1/26/2022 9:00 AM Licensing Program Analysts (LPA) Jeevun Birk-Miller and Fabiola Diaz conducted an unannounced complaint investigation inspection and met with Licenseee, Sandra Gomez to deliver findings for the above allegations. It was alleged that staff working in the facility did not have the required documents and training completed prior to assisting with children. During the course of the investigation, LPA Birk-Miller conducted interviews with the Licensee, staff, parents, and children in care. During the inspection on 10/27/2021 LPA observed the Licensee's husband assisting with the children. Licensee's husband did not have the required documents or trainings in his file. LPAs Birk-Miller and Diaz had explained what is required to licensee. Licensee stated she had all the documents completed and trainings prior to them working with the children, but did not have the file. The facility has a new assistant working and LPAs verified the requirements were met. Based on file review, interviews, and observation the Licensee did not ensure that a person who was assisting had the required trainings or documents on file. Based on the file review and observation conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Continue to 9099-C page of this document...
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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 6
Control Number 53-CC-20211021081752
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: 01/26/2022
NARRATIVE
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It was alleged that children were buckled in a highchair and had been crying. It was alleged that children are buckled in a highchair with games or something to do. Licensee stated that when the children are eating they are in the highchairs. Licensee stated for the little children she will place them in the highchair to do activities, such as art projects. Licensee explained that this was to ensure the safety of the children while they did activities. Licensee stated she does not leave children in highchairs for more than 15-20 minutes and they are always doing something while in them. Licensee had provided photos of children doing activities while in the highchairs. Interviews with parents stated that children had only been seen in highchairs when eating or doing an activity. Based on interviews and observation the Licensee was seen to using highchairs for purposes other than eating. Based on the file review and observation conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following Type B citations were given during the inspection on the LIC9099-D page of this report. An exit interview was conducted with the Licensee. A Notice of Site Visit was posted by LPA Birk-Miller and this shall be posted for 30 days.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 53-CC-20211021081752
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: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2022
Section Cited
CCR
102416.1(a)(1-12)
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(a) Personnel records shall be maintained on each employee and shall contain the following information: (1) Employee's full name. (2) Driver's license number if the employee is to transport children. (3) Date of employment. (4) Date of birth. (5) Current home address and phone number.(6) Documentation of completion of training on preventative health practices as required by Section 102416(c). (7) Past experience, including types of employment and former employers. (8) Duties of the employee. (9) Termination date if no longer employed.
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This requirement was not met as evidenced by: Based on interviews, file review, and observation the facility did not ensure that individuals assisting with children had the required documents and trainings prior to assisting with children. This poses a potential health and safety risk to children in care.
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(10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417. (11) A signed statement regarding their criminal record history as required by Section 102370(c). (12) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 102370(d).
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Licensee corrected this deficiency during the inspection through providing the new assistants file for review. Licensee understands that she must have staff complete the required documents and training prior to working with children in care.
Type B
02/02/2022
Section Cited
CCR
102423(a)(2)
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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
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Licensee understands that highchairs are only to be used while the children are eating. Licensee agrees to submit a written statement regarding the use of highchairs to the LPA. Licensee provided the statement during the inspection.
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This requirement was not met as evidenced by: Based on interviews and observation the facility did not ensure that children were using highchairs for things other than its intended purpose. This poses a potential health and safety risk to children in care.
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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/21/2021 and conducted by Evaluator Jeevun Birk
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20211021081752

FACILITY NAME:GOMEZ, SANDRAFACILITY NUMBER:
343622657
ADMINISTRATOR:GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:8774 CLAY GLEN WAYTELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 8DATE:
01/26/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Sandra GomezTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Children were left alone with unfingerprinted adult
INVESTIGATION FINDINGS:
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***THIS IS AN AMENDED REPORT*** On 1/26/2022 9:00 AM Licensing Program Analysts (LPA) Jeevun Birk-Miller and Fabiola Diaz conducted an unannounced complaint investigation inspection and met with Licensee, Sandra Gomez to deliver findings for the above allegations. It was alleged that children were left alone with an unfingerprinted adult. LPA Birk-Miller conducted interviews with the Licensee, staff, parents, and children in care. LPA also conducted observations and gathered documents. Licensee stated she had not left children in the care of someone who was not fingerprint cleared. She stated she gets those who will be assisting fingerprinted. LPAs observed that the person in question had been fingerprint cleared at the time of the inspections, but the start date for this assistant was unclear. The information gathered was inconsistent and the LPA was unable to corroborate the allegation. Based on the information obtained throughout the course of this investigation the above allegations could not be substantiated or dismissed. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the finding is UNSUBSTANTIATED. An exit interview was conducted with the Director. Notice of Site Visit was provided and shall remain posted for 30 days.

Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 53-CC-20211021081752
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: 01/26/2022
NARRATIVE
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***THIS IS AN AMENDED DOCUMENT***
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6