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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500171
Report Date: 03/02/2022
Date Signed: 03/02/2022 05:44:04 PM


Document Has Been Signed on 03/02/2022 05:44 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:GONZALEZ, MA NATIVIDADFACILITY NUMBER:
394500171
ADMINISTRATOR:GARCIA, NATIVIDADFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 642-3525
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:14CENSUS: 12DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Ma Natividad GonzalesTIME COMPLETED:
05:50 PM
NARRATIVE
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On Wednesday, March 2,2022, Licensing Program Analyst (LPA) Elvira Sierra met with the licensee, Ma. Natividad Gonzalez, for the purpose of an unannounced annual random inspection. The licensee's assistant was also present during the inspection. Facility hours of operation are 24 hours 7 days a week. A review of the Facility Personnel Summary shows that all adults living and working in the home have criminal record clearances on file with Licensing Office. Licensee stated that no new residents moved into the home since licensure. Upon arrival present in the facility were 12 children (5 infants, 4 school age and 3 preschool children). Licensee's husband arrived later during the inspection.

A health and safety inspection was conducted in all areas accessible to children. Off limit areas are: Entire second floor, Bedroom # 1, Pantry and Garage on ground floor. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. Facility maintains a working phone, 2A10BC fire extinguisher, and functioning smoke/carbon monoxide detector. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safety latches are in use on some kitchen cabinets and bathroom cabinets and drawers. The applicant understands that she must ensure the safety latches are not broken. Stairs leading to the second floor is appropriately barricaded.

At 3:00 pm LPA asked Licensee for the facility records which include children and staff files. 12 of children’s files and 2 of staff files were reviewed. LPA reviewed staff files and licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in person EMSA CPR and First Aid certification was verified and expires on 08/2022. LPA observed a current roster and fire drills are conducted at least once every six months.

Report continues on subsequent page 809C---
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171
VISIT DATE: 03/02/2022
NARRATIVE
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LPA verified the annual fees are current. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm



LPA discussed safe sleep regulations with Licensee and discussed Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email 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/process.
Report continues on subsequent page 809C--
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171
VISIT DATE: 03/02/2022
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Title 22 Deficiency is being cited on the subsequent page 809D Upon receipt of Type A citations, the Licensee shall post and provide copies of the LIC 809D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809D in each child's file. Appeal Rights and Notice of Site Visit were provided.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee, Ma Natividad Gonzalez.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/02/2022 05:44 PM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.465


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. Upon arrival present in the facility were 5 infants, 4 school age and 3 preschool which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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One infant was removed durint the visit. Licensee stated some of the chidlren that were present today are not normally at the facility all this time. Licensee stated she will make sure that no more than 4 infants will be present at the same time. LPA and Licensee reviewed capacity regulations.
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: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4