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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 313623618
Report Date: 11/26/2024
Date Signed: 12/03/2024 12:23:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2024 and conducted by Evaluator Erwina Pascual-Golamco
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20241122114917
FACILITY NAME:MUNOZ, GISELA & SANDROFACILITY NUMBER:
313623618
ADMINISTRATOR:MUNOZ, GISELA & SANDROFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 223-2415
CITY:ROSVILLESTATE: CAZIP CODE:
95747
CAPACITY:14CENSUS: 8DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gisela MunozTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Licensee not providing safe sleep environment for infant.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Erwina Pascual-Golamco and Soleil Marx (LPA) met with Licensee, Gisela Munoz, for the purpose of conducting an investigation to open and close a complaint. The purpose of today's inspection was explained.
LPAs toured the facility, including all areas accessible to children. LPAs observed census included 8 children being supervised by Licensee and assistants. This facility operates Monday through Friday, 8AM to 4:30PM.

During today's inspection, LPAs observed Licensee provide care to children, conducted interview, and requested facility documents. LPAs observed two pack and plays used for infants that were not covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. LPAs asked licensee to review safe sleep logs for infants, and licensee stated she does not have documentation. Licensee stated they have been enrolled in the program since September and October of 2024. continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 03-CC-20241122114917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MUNOZ, GISELA & SANDRO
FACILITY NUMBER: 313623618
VISIT DATE: 11/26/2024
NARRATIVE
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LPA discussed the 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 as an additional resource. 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.

Based on LPA's observation, interview, and record review, it was determined that the Licensee is not providing a safe sleep environment for infants in care. The preponderance of evidence standard has been met, and the allegation is SUBSTANTIATED.

A Type A deficiency is issued on the attached LIC9099-D page. Licensee shall provide a copy of this licensing report 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. Exit interview was conducted with Licensee, appeal rights were provided, and A notice of site visit was given to Licensee, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20241122114917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MUNOZ, GISELA & SANDRO
FACILITY NUMBER: 313623618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
102425(a)(3)
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102425 Infant Safe Sleep(a)There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3)Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.
This requirement is not met as evidenced by:
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Licensee stated she will order fitted sheets today. LPA will conduct a POC visit.
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Based on observation and interview, the licensee did not comply with the section cited above as LPAs observed two pack and plays used for infants that were not covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged, which poses an immediate health, safety or personal rights
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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.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20241122114917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MUNOZ, GISELA & SANDRO
FACILITY NUMBER: 313623618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
102425(j)(2)(D)
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102425 INFANT SAFE SLEEP
(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2) The provider shall check and document the following:(D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:...a.Date.
b. Infant’s name.c.Time of each 15-minute check. This requirement is not met as evidenced by:
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Licensee stated she will start safe sleep log documentation starting today and will keep in infant files. LPA will conduct POC visit.
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Based on record review and interview, the licensee did not comply with the section cited above by LPAs asked licensee to review safe sleep logs for infants, and licensee stated she does not have documentation. Licensee stated they have been enrolled in the program since September and October of 2024.
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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.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4