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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376620000
Report Date: 08/02/2024
Date Signed: 08/02/2024 09:15:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2024 and conducted by Evaluator Annette Sutherland
COMPLAINT CONTROL NUMBER: 51-CC-20240514082231
FACILITY NAME:CRUZ, GUADALUPE & GONZALEZ, MATILDE FCCFACILITY NUMBER:
376620000
ADMINISTRATOR:GUADALUPE C. & MATILDE G.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 249-0539
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:14CENSUS: 6DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Matilde GonazalezTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Licensee did not ensure child's immunization records were maintained at the facility.
INVESTIGATION FINDINGS:
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On 8/2/24 at 10:00 AM, Licensing Program Analyst (LPA) Annette Sutherland conducted an unannounced complaint inspection to deliver findings regarding the above allegations. LPA Sutherland met with Licensee Matilde Gonazalez. Census was 6 children.
During the investigation, LPA reviewed childrens files and conducted interviews.
Based on information obtained, there was an incomplete file for a child in care (#C1). Licensee was able to have Guardian of child complete and submit file for child.
The preponderance of evidence standard has been met, therefore the above allegation found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 or Health and Safety Code are being cited on the attached LIC 9099D. Exit interview was conducted with Licensee Matilde Gonazalez, and a Notice of Site Visit was provided. Notice of Site visit was given, posted and will remain posted for 30 days
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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 2
Control Number 51-CC-20240514082231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CRUZ, GUADALUPE & GONZALEZ, MATILDE FCC
FACILITY NUMBER: 376620000
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
102418(g)(1)
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102418 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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home. This requirement was not met as evidenced by…
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Licensee has now provided proof for immunizations for (C#1) and understands that every child prior to enrollment must have a complete file for review by licensing Department.
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Based upon facility document review. Licesneee was unable to provide proof of file for (C#1) which poses a potential health, safety and personal rights risk to children in care.
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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: Joelle Redding
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2