426210992-12-17-2021-17-CC-GMIE-CA8RD9-20211231115531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 426210992
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:54:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2021 and conducted by Evaluator Gigi Reyes

PUBLIC

COMPLAINT CONTROL NUMBER: 17-CC-20211029161710

FACILITY NAME:	GOMEZ FAMILY CHILD CARE		FACILITY NUMBER:	426210992
ADMINISTRATOR:	MARIA RAQUEL GOMEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 693-0768
CITY:	LOS OLIVOS	STATE: CA	ZIP CODE:	93441
CAPACITY:	14	CENSUS: 5	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Raquel Gomez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Child sustained injuries while in care.
Facility did not inform parent of incidents.

INVESTIGATION FINDINGS:

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On 12/17/2021 Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced inspection to deliver the finding on the above allegations. 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 chilren present during the inspection.

Regarding the allegation, Child sustained injuries while in care, LPA's interview with Licensee on 11/1/2021 revealed that on 10/14/2021 on or about 10:30 AM, during outside play time, C1 slid and fell on C1's back, C2 slid and fell bumping into C1. Licensee acknowledged that bruising occurred at the facility.

On 11/22/2021, LPA interviewed Child# 2 (C2), C2 stated that C2's friends including C1 were running and playing by the chicken cage when Child 1 slid down the hill on C1's back and fell, C2 slid down after and bumped into C1.

Continued on LIC 9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 17-CC-20211029161710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 426210992
	VISIT DATE: 12/17/2021

NARRATIVE

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LPA observed that backyard is a sloping hill with dried leaves, twigs and pebbles.

LPA’s review of police report revealed Child # 1 is too young to be able to articulate how or when the bruising was sustained. Police interview with medical professional revealed that bruising/injuries were of "no consequence" . Police report stated there is no sufficient evidence to show that any crime occurred. LPA's review of medical report revealed the cause/s of marks are very difficult to determine.

LPA interview with parents also revealed that they were satisfied with the care and supervision provided by the Licensee. Parents also stated that injuries obtained by child/children at day care were incidents of children being active and playful.

Based on LPA interviews and record reviews, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. No deficiency was cited, a Technical Violation on Personal Rights was issued.

Regarding the allegation, Family Child Care Home (FCCH) did not inform parent of the incident, On 10/14/2021, Child #1 (C1) sustained bruise at FCCH, small cut on the lip and bruises on C1's back. LPA interview with Licensee on 11/1/2021 revealed that during outside playtime, C1 slid and fell on sloped ground then another child, Child # 2 (C2) slid and fell bumping into C1

Licensee failed to notify Child # 1's authorized representative of the incident that occurred at FCCH which Licensee admitted. Licensee stated there was another parent picking up a child and day care children were children with Licensee by the door that Licensee completely forgot informing the parent of C1.

Continued on LIC 9099 C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 17-CC-20211029161710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 426210992
	VISIT DATE: 12/17/2021

NARRATIVE

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Based on LPA interview and document review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiency is being cited in accordance to Title 22 of the California Code of Regulations and/or Health & Safety codes. Please refer to LIC9099 D for documentation of deficiency cited:

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.

Exit interview conducted with Licensee Maria Raque 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 Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 17-CC-20211029161710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 426210992
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2021 Section Cited CCR 102416.2(g)	1 2 3 4 5 6 7	In addition to the requirements of Health and Safety Code Section 1597.467(a), no later than the same business day, the licensee shall notify a child's parent.... This requirement is not met as evidenced by	1 2 3 4 5 6 7	During today's visit, Licesee submitted a written plan of correction to LPA stating Licensee will ensure that all incidents/injuries requireing medicl treatment will be reported to CCLD with 24 hours. LIC 624 Unusual incident report was also submitted.
	8 9 10 11 12 13 14	Based on LPA interview and document review, Licensee admitted that Licensee failed to notify parent of the incident that occurred at FCCH on 10/14/2021. This poses a potential risk to health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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