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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016194
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:43:01 AM

Document Has Been Signed on 06/22/2023 11:43 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
198016194
ADMINISTRATOR:GONZALEZ, BERENICEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 269-0245
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee - Citlaly GonzalezTIME COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) R. Derraco conducted an unannounced case management visit to the above mentioned facility on 06/22/23. LPA arrived at the facility at 11:00 AM and was met by licensee, Citlaly Gonzalez, who guided analyst on a tour of the facility. LPA observed 1 additional adult and 10 children in care during the visit. The home was observed to be clean and in good repair.

The purpose of this visit is to issue a citation to the licensee for not reporting an unusual incident that occurred the week ending March 03, 2023. During the visit, LPA advised licensee to report any unusual incident by calling Monterey Park Southwest's On Duty Analyst within 24 hours of an incident occurring and to submit a written report on LIC 624B - Unusual Incident/Injury Report - Family Child Care Homes within 7 days. Licensee was advised that a citation under California Code of Regulation Section 102416.2(b)(3)(C) will be issued.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Citlaly Gonzalez

SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 11:43 AM - It Cannot Be Edited


Created By: Randy Derraco On 06/22/2023 at 11:19 AM
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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 198016194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2023
Section Cited
CCR
102416.2(b)(3)(C)

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102416.2 Reporting Requirements (b) the licensee will report to the Department any of the events...that occur during the operation of a daycare. (3) Health and Safety Code... (C) Any unusual incident that threatens the physical... health or saftey of any child. This requirement is not met as evidenced by:
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LPA discussed Unusual Incident Reporting procedures with licensee during visit.
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Based on interview and record review, the licensee did not report an unusual incident that occured on 03/03/23 which poses a potential Health, safety and/or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Karen Chambers
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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