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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 136610649
Report Date: 06/02/2025
Date Signed: 06/02/2025 04:46:35 PM

Document Has Been Signed on 06/02/2025 04:46 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CAREFACILITY NUMBER:
136610649
ADMINISTRATOR/
DIRECTOR:		CAROLINA GAXIOLA-GASTELUMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 364-8796
CITY:BRAWLEYSTATE: CAZIP CODE:
92227
CAPACITY: 11TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
06/02/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Carolina Gaxiola-Gastelum TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 6/2/2025, at 1:15pm, Licensing Program Analyst (LPA), Vicky Williamson conducted an unannounced annual random inspection. LPA met with Licensee, Carolina Gaxiola-Gastelum and disclosed the purpose of the inspection. There were eight (8) napping daycare children present with one (1) infant who was awake. Also present was Licensee’s Assistant, Evelyn Rivera. Days and hours of operation are Monday through Friday, 5:00am – 4:00pm.

During the inspection, LPA’s review of the Guardian Employee Roster determined that Evelyn Rivera does not have a criminal record clearance. Per Licensee, Evelyn Rivera has been employed at the daycare since 5/16/2025. At 1:30pm, Licensee’s Assistant Evelyn Rivera left the daycare home and Licensee’s Assistant, Claudia Espinoza arrived at the daycare home.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA accompanied by licensee toured the inside and outside of the home. This is a single story, four (4) bedroom, two (2) bathroom apartment. The following areas are used for daycare: living room, dining room, bedroom 4, bathroom 2 and the patio. The off-limit areas include bedroom 1 (master bedroom), bedroom 2, bedroom 3, bathroom 1 (inside of master bedroom) and the kitchen. Off limit areas are made accessible by use of safety gates, and door safety locks. See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 06/02/2025
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Licensee utilizes the front fenced patio for outdoor activities for the children. Licensee was reminded that there must always be direct supervision of the children while outdoors. Licensee stated that she understood. LPA advised the Licensee that prior to making alterations or additions to the home or grounds, the Licensee shall notify the Department of the proposed change.

The home is clean, orderly and has adequate ventilation. Licensee has children's toys, play equipment and books available. Licensee has a working cell phone. All poisons, detergents, cleaning compounds, medications and other hazardous items in the home are made inaccessible to children through latches, locks, and/or placed on high surfaces. The fire extinguisher, smoke and carbon monoxide detectors meet requirements and are operational.

Licensee stated there is a community swimming pool on the premises. LPA observed an in- ground swimming pool, with 5 ft fencing, a gate that swings away from the pool, is self-closing and self-latching. Licensee stated that a key is used to enter the gate. Licensee stated there are no firearms, other weapons, or ammunition in the home.

Pediatric CPR/First Aid certification for licensee is valid through 2/18/2026. Licensee's Assistant, Claudia Espinoza completed Basic Life Support certification instead of Pediatric CPR/First Aid certification. Licensee and assistant have required immunization records on file. Mandated Reporter training certification for licensee was completed on 2/18/2024 and for assistant 8/8/2024. LPA informed licensee to ensure that Pediatric CPR/First Aid certification and mandated reporter training is completed once every two years. LPA observed the required documents posted. A sample of children’s files were reviewed and were determined to be complete. Safe Sleep Logs documenting 15-minute sleep checks for Child 1 (C1) were not current; last date documented was 3/3/2025. During the time of inspection, LPA observed a play yard blocking the sliding door that exits to the patio used for outdoor play. The last fire and disaster drill was conducted and documented on 5/19/2025.

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.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 06/02/2025
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LPA discussed safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
LPA reviewed PIN 20-24-CCP regarding Safe Sleep with licensee. Licensees stated that she understood.
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.

LPA and licensee discussed and reviewed the following: Report suspected child abuse and neglect, form LIC 311D, maintaining children’s records according to regulation, posting required forms. Licensee is reminded that corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare. Licensee was also provided information regarding SIDS, Lead Exposure and Shaken Baby Syndrome.


LPA discussed and provided Licensee with the following: childcare advocates email address: childcareadvocatesprogram@dss.ca.gov. In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Please visit the Guardian web page and set-up your Guardian account. https://cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian. If you have any questions regarding Guardian, please contact CDSS at email: guardian@dss.ca.gov.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 06/02/2025
NARRATIVE
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To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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.

Licensee completed the Health and Safety Issues Family Child Care Regulation 102417 form during time of inspection.



Per California Code of Regulations, Title 22, Division 12, Chapter 3, deficiencies are being cited on the attached LIC 809D. Two Technical violations were issued.

Based on interviews and record review, one (1) Type A deficiency of California Code of Regulations, Title 22, Division 12, Chapter 3, is being cited on the attached LIC 809D. A $500 Civil Penalty was issued.

LPA informed Carolina Gaxiola-Gastelum that this report dated 6/2/2025 documents one (1) Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed Licensee, Carolina Gaxiola-Gastelum to provide a copy of this licensing report dated 6/2/2025 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. LPA provided Licensee, Carolina Gaxiola-Gastelum with form LIC 9224.

See LIC 809C Continuation...
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649
VISIT DATE: 06/02/2025
NARRATIVE
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During the exit interview, the Licensee, Carolina Gaxiola-Gastelum confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit (LIC 9213) was given to Licensee, Carolina Gaxiola-Gastelum and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. LPA observed LIC 9213 was posted. Appeal Rights (LIC 9058) was provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and the report was reviewed with the Licensee, Carolina Gaxiola-Gastelum
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Vicky Williamson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2025 04:46 PM - It Cannot Be Edited


Created By: Vicky Williamson On 06/02/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that Licensee's Assistant Evelyn Rivera did not have a criminal record clearance and has been employed at the daycare since 5/16/2025 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Licensee stated that she will ensure that fingerprint submission for Assistant Evelyn Rivera is completed and that she obtains a criminal record clearance prior to her presence in the daycare. Licensee was advised to follow up with the Guardian system and provide proof of status and clearance to the Department, no later than 6/3/2025.
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.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2025 04:46 PM - It Cannot Be Edited


Created By: Vicky Williamson On 06/02/2025 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GAXIOLA-GASTELUM, CAROLINA FAMILY CHILD CARE
FACILITY NUMBER: 136610649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that documentation of 15 minute sleep checks were not current for C1 during time of inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2025
Plan of Correction
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Licensee stated that she will submit proof of documentation for 15 minute sleep checks for C1 for the period of 6/3/2025 - 6/6/2025 to the SDRO, no later than 6/9/2025.
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.
Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:
Vicky Williamson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2025


LIC809 (FAS) - (06/04)
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