<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417109
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:05:02 PM

Document Has Been Signed on 09/01/2022 02:05 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197417109
ADMINISTRATOR:MARTINEZ/GUMERCINDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 533-9317
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH: Gumercinda MartinezTIME COMPLETED:
02:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/01/2022, Program Licensing Analyst, (LPA) Justin Dorsey conducted an unannounced case management inspection. Upon arrival LPA was greeted by Licensee Gumercinda Martinez who guided analyst on a tour of the home. The purpose of this inspection is to discuss the background check Case Closure for Adult #1.

Licensee stated Adult #1 does not live in the home. Per licensee in January of 2020 Adult #1 worked in the home for about 2 months. According to the licensee Adult #1 never lived in the home. LPA Dorsey toured the home and did not observe Adult #1. Present in the home during the visit was the licensee, Adult #2 and Family Member #1.

The licensee was informed that all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week.

LPA gave instructions to post LIC 9213 for 30 days. The report done today must be kept in your facility and available for public review for at least three years.

There were no Title 22 deficiencies cited during today's visit. Exit interview was conducted, copy of this report, notice of site visit were provided to Licensee Gumercinda Martinez.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1