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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426210992
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:00:16 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:
12/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Raquel GomezTIME COMPLETED:
03:00 PM
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On 12/17/2021 Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection. Prior to inspection, LPA asked pre screening questions related to COVID 19, Licensee's responses indicate there was no COVID exposure on site. LPA met with Licensee and explained the nature of the inspection. There were 5 children present during the inspection.

LPA's interview with Licensee on 11/1/2021 revealed that On 10/14/2021, when day care children were playing in the backyard, C1 slid and fell down the sloping hill, then C2 slid and fell and hit C1. Child # 1 sustained bruise at FCCH, small cut on the lip and bruises on Child # 1's back.

Licensee did not notify Community Care Licensing of the incident, Licensee stated Licensee was not aware that Child # 1 was brought to the doctor.

During today's inspection, no deficiency cited, a Technical Violation on Reporting Requirements was issued.

Exit interview conducted with Licensee Maria Raquel Gomez. Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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