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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622657
Report Date: 07/26/2023
Date Signed: 07/26/2023 11:59:13 AM


Document Has Been Signed on 07/26/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOMEZ, SANDRAFACILITY NUMBER:
343622657
ADMINISTRATOR:GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 9DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sandra GomezTIME COMPLETED:
12:30 PM
NARRATIVE
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On July 26, 2023, at 8:55 am Licensing Program Analyst (LPA) Corina Beckby met with Licensee Sandra Gomez for the purpose of an unannounced annual inspection. LPA provided and reviewed the Family Child Care Home Entrance Checklist. LPA observed 9 children being supervised by Licensee. All individuals subject to criminal background review have obtained a criminal record clearance. Facility days and hours of operation are Monday - Friday from 5:30 am to 5:30 pm.

Licensee guided LPA on a tour of the facility and a health and safety inspection was conducted in all areas accessible to children. The off-limits areas include the second floor, garage and south side of the backyard. Licensee acknowledges that children may never enter the off limit areas. LPAs observed the required postings, a fully charged fire extinguisher, and smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home. No bodies of water were observed today. Toxic and hazardous items are inaccessible to children.

LPA reviewed 9 children’s files. A current children’s roster and fire drill was observed. LPA discussed the requirement of renewing CPR and mandated reporter training every 2 years. Licensee’s CPR is current and expires 11/04/23. Licensee’s mandated reporter could not be verified. Mandated reporter training can be renewed at mandatedreporterca.com.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. (Report continues LIC809-C)
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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Document Has Been Signed on 07/26/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that Licensee was caring for 9 children by herself putting her out of ratio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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Licensee will no longer accept School Age drop-ins, Licensee will have assistant start at 8:00 am. Licensee will have a visual schedule of children's hours of care to stay in ratio. This deficiency was corrected at time of visit.
Section Cited
Deficient Practice Statement
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No Deficiecny
POC Due Date: 07/26/2023
Plan of Correction
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No Deficiency
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 counts of missing Mandated Reporter Certificates for self and Assistnt, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee will provide LPA copies of certificates to LPA via email or text by 8/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657
VISIT DATE: 07/26/2023
NARRATIVE
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If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Continued on LIC809-C...
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657
VISIT DATE: 07/26/2023
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During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was posted by LPA and must remain posted for 30 days.

Exit interview was conducted and report was reviewed with the licensee, Sandra Gomez. During today’s inspection a Type A deficiency was issued that is an immediate health and safety, or personal risk to persons in care. In addition, a Type B deficiency was issued that is a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for each deficiency. Upon receipt of a Type A deficiency, licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed. Licensee was provided with Appeal Rights.

The Type A was corrected during visit.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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