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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210992
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:49:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
426210992
ADMINISTRATOR:MARIA RAQUEL GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 693-0768
CITY:LOS OLIVOSSTATE: CAZIP CODE:
93441
CAPACITY:14CENSUS: 5DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria Raquel GomezTIME COMPLETED:
11:30 AM
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On 11/23/2021, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management Inspection to obtain signature on the LIC 9099 Report generated on 11/22/2021. The stated report was not signed due computer consistency check. Prior to inspection, LPA asked Pre screening questions related to COVID - 19, Licensee's response indicates there was no COVID 19 exposure on site.

LPA met with Licensee, Ms. Maria Raquel Gomez and explained the purpose of the inspection. There were five (5) children present during the inspection.
LIC 9099 Complaint Investigation Report was read, signed and handed to Licensee.

Exit interview was conducted with Licensee.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL BE ASSESSED.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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