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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376626037
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:13:37 PM


Document Has Been Signed on 06/07/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501



FACILITY NAME:GOMEZ, SILVIA FAMILY CHILD CAREFACILITY NUMBER:
376626037
ADMINISTRATOR:SILVIA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 224-7152
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:14CENSUS: 9DATE:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Silvia GomezTIME COMPLETED:
02:15 PM
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On the above date and time, Licensing Program Analyst (LPA) Jessica Rubio arrived unannounced to the facility to conduct a case management visit due to an unusual incident report submitted for an incident that occurred on 5/16/2022 regarding a parent disclosing a child (C1) disclosed that a staff member (S1) pulled C1's shirt up and hit C1 on the stomach. LPA met with Licensee Silvia Gomez and conducted census. LPA conducted interviews with the Licensee, S1, one child (C2). LPA determined that the facility was not in violation of Title 22 Regulations. There were no citations issued during this visit. An exit interview was conducted, a copy of this report, LIC 811 (Confidential Names List) and appeal rights were reviewed with and provided to Licensee Silvia Gomez.

A Notice of Site Visit was also provided and shall remain posted for 30 days.

SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 255-4093
LICENSING EVALUATOR NAME: Jessica M RubioTELEPHONE: (951) 233-9356
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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