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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215912
Report Date: 05/05/2022
Date Signed: 05/05/2022 10:13:50 AM


Document Has Been Signed on 05/05/2022 10:13 AM - 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
426215912
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Liliana GomezTIME COMPLETED:
10:15 AM
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On May 5, 2022 at 9:00 AM, Licensing Program Analyst Gigi Reyes conducted an unannounced Case Management Inspection at the above Family Child Care Home (FCCH). Licensee applied for increase in capacity from Small FCCH to Large FCCH. LPA asked pre screening questions related to COVID- 19 and licensee’s responses indicate there are no COVID 19 exposures on site. LPA met with Licensee Liliana Gomez and discussed the purpose of the inspection.

LPA toured the home inside and outside and observed as follows. There were 5 children present during the inspection. The required 2A10 BC fire extinguisher was purchased on 1/6/2022 and was mounted in the wall at the day care area. Licensee was reminded to replace or service the fire extinguisher every year. The carbon monoxide and smoke detector was tested and functional at the time of inspection.

Fire Safety inspection clearance was granted on 4/25/2022.

Today, FCCH meets the California Code of Regulations Title 22 Division 12 and Health and Safety Code. A License for Large Family Child Care Home is granted effective today, 5/5/2022.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Liliana Gomez
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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