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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840710
Report Date: 11/16/2023
Date Signed: 11/16/2023 11:42:37 AM

Document Has Been Signed on 11/16/2023 11:42 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
RIVERSIDE SOUTH EAST, 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: 10CENSUS: 10DATE:
11/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Irma GomezTIME COMPLETED:
11:55 AM
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On 11/16/2023, a case management visit is being conducted in response to information reported to the Department in regard to the facility. LPA conducted a tour of the facility and interviewed Licensee and assistant. Based on information gathered, no violations have been identified and no further follow up is needed.
An exit interview was conducted and a copy of this report was provided to licensee, Irma Gomez.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Lorena Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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