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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622657
Report Date: 07/27/2023
Date Signed: 07/27/2023 01:11:08 PM

Document Has Been Signed on 07/27/2023 01:11 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOMEZ, SANDRAFACILITY NUMBER:
343622657
ADMINISTRATOR:GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
07/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sandra GomezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Corina Beckby met with the Licensee, Sandra Gomez for the purpose of a case management visit. LPA observed Licensee and assistant, caring for 10 of children including 2 infants.

Licensee stated she spoke with several parents and advised them about staying on schedule. LPA observed a new schedule for all enrolled children and list of 4 children who will no longer attend the facility August 7, 2023 due to school beginning. LPA verified that Licensee is in ratio and has made the proper changes needed to ensure compliance.

An Exit interview was conducted, and the report was reviewed and provided to Licensee. LPA discussed and provided Appeal Rights to Licensee. LPA posted the Notice of Site Visit and Licensee acknowledges it must remain posted for 30 days. A Failure to comply with posting requirements shall result in an immediate civil penalty of $100
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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