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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622657
Report Date: 06/17/2024
Date Signed: 06/17/2024 03:04:22 PM

Document Has Been Signed on 06/17/2024 03:04 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/
DIRECTOR:		GOMEZ, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 670-8519
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
06/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Sandra GomezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Sandra Gomez is Spanish speaking and Licensing Program Analyst (LPA) Corina Beckby spoke with Licensee in Spanish and translated the conversation to English below.

On 06/17/24 Licensing Program Analyst (LPA) Corina Beckby, conducted an unannounced annual inspection and met with Licensee, Sandra Gomez. LIC (126), Entrance Checklist for Family Child Care Homes, was provided and reviewed with Licensee. Present in the facility was Licensee supervising 4 children including 1 infant. Facility hours of operation are Monday – Friday from 7:30 am – 5:30 pm. LPA verified that annual fees are current.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.



A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. Off-limit rooms are: second floor, garage, and south side of the backyard. Off-limits areas will remain inaccessible to children by closed doors, gates, and/or supervision. The licensee
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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657
VISIT DATE: 06/17/2024
NARRATIVE
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acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa. Toys appear to be safe and in working order. Cleaning agents and detergents are made inaccessible to children. Poison, toxic and hazardous times are made inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 2A10BC fire extinguisher. Sharp utensils are inaccessible to children. Licensee understands that she must ensure the safety locks are not broken. The backyard is fenced and has sufficient toys. Licensee states there are no weapons in the home.

LPA reviewed 3 children’s files. LPA observed 15-minute observation checks for napping infant. CPR and first aid training was not verified for Licensee. CPR expired on 09/11/25. Mandated Reporter Training certificate expires: 08/21/25. Licensee understands the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com.

Licensee currently has no children enrolled that require IMS. Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.



Licensee has 1 infant currently enrolled. Licensee is maintaining sleep logs for all infants in care (under 24 months) are being maintained in children’s files.

Report continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657
VISIT DATE: 06/17/2024
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LPA discussed the safe sleep regulations with Licensee and provided 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.

LPA encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

During the exit interview, the Licensee, Sandra Gomez, confirmed there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California. LPA reminded Licensee to advise the department of any and all facility closures (vacations, Holidays, and illness).

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Report continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657
VISIT DATE: 06/17/2024
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LPA informed Licensee, Sandra Gomez, that this report dated 06/17/2024, documents a Type A citation that is an immediate Health and Safety, or Personal Rights risk to persons in care. In addition, Type B citations were issued that are a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for each deficiency.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with Licensee, Sandra Gomez. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
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Document Has Been Signed on 06/17/2024 03:04 PM - It Cannot Be Edited


Created By: Corina Beckby On 06/17/2024 at 02:43 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 infant's files did not have an Individual Sleeping Plan was not available for a 4 month old, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee will have completed and signed form in infants file. LPA will return to verify form is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


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Document Has Been Signed on 06/17/2024 03:04 PM - It Cannot Be Edited


Created By: Corina Beckby On 06/17/2024 at 02:43 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in a fire drill could not be produced, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Licensee will conduct and fire drill with children present. LPA will return to verify compliance.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in she allowed her CPR to expire, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Licensee will sign up for a CPR course and send valid CPR card via email to LPA by due date.
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 03:04 PM - It Cannot Be Edited


Created By: Corina Beckby On 06/17/2024 at 02:43 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOMEZ, SANDRA
FACILITY NUMBER: 343622657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 3 of the 6 children's files were not available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Licensee will collect all required documents by due date. LPA will return to verify compliance.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that a current roster was not available at time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Licensee will update roster and LPA will return to verify compliance.
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


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