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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376622797
Report Date: 10/08/2020
Date Signed: 10/08/2020 01:49:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GONZALEZ, MARIA FAMILY CHILD CAREFACILITY NUMBER:
376622797
ADMINISTRATOR:MARIA GONZALEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 746-6880
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:14CENSUS: 10DATE:
10/08/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Maria Gonzalez TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management visit to review Provider Information Notice (PIN) 20-24-CCP – Recently Approved Safe Sleep Regulations in Effect. Due to the COVID 19 pandemic, this inspection was done as a tele visit upon FaceTime. Present in the home was the Licensee, one (1) assistant, two (2) infants, four (4) toddlers) and four (4) school aged children

On 09/15/2020, PIN 20-24-CCP was issued. LPA electronically provided Licensee with PIN 20-24-CCP and the LIC 9227 Individual Infant Sleeping Plan form. Licensee and LPA discussed PIN 20-24-CCP and LIC 9227 form. The Licensee stated she will immediately begin to use the LIC 92227.

An exit interview was conducted. A copy of this report and Licensee/Appeal Rights (LIC 9058) will be e-mailed to the Licensee. The Licensee was advised that acknowledgement of the receipt of the report is to be received within twenty-four hours.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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