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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840710
Report Date: 02/15/2023
Date Signed: 02/15/2023 10:48:40 AM

Document Has Been Signed on 02/15/2023 10:48 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GOMEZ FAMILY CHILD CAREFACILITY NUMBER:
334840710
ADMINISTRATOR:GOMEZ, IRMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 347-1176
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
02/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Irma GomezTIME COMPLETED:
10:54 AM
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Licensing Program Analyst, LPA, Jeanette Sanchez, made an unannounced Case Management visit on this date to deliver an amended LIC 809 and LIC809D to remove a deficiency cited during the annual inspection on 02/08/23. LPA is amending report due to submission of proof that was submitted after inspection was completed and deficiency was cited. LPA met with licensee Irma Gomez.

An exit interview was conducted, and this report was reviewed with the licensee Irma Gomez. Appeal rights were discussed and provided during the exit interview.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Stephanie Hudak
LICENSING EVALUATOR NAME: Jeanette Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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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