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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628572
Report Date: 09/08/2025
Date Signed: 09/08/2025 02:27:46 PM

Document Has Been Signed on 09/08/2025 02:27 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GOMEZ, CINTHYA FAMILY CHILD CAREFACILITY NUMBER:
376628572
ADMINISTRATOR/
DIRECTOR:		CINTHYA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 253-7472
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
09/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Cinthya GomezTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 9/8/2025, at 1:30 PM Licensing Program Analyst (LPA) Shannan Williams conducted an unannounced case management inspection in conjunction with complaint investigation on 9/8/2025. LPA met with Licensee, Cinthya Gomez and accompanied by licensee proceeded to tour the facility. There were two (2) children present at the facility at the time of the inspection.

During the course of a complaint investigation conducted on 9/8/2025, the Licensee admitted that she allowed two children, ages 5 and 7 years old, to play inside an infant crib that was not age appropriate equipment, and without assistance from the Licensee Child #2 (C2) jumped out of the crib, caught her foot on the ledge of the crib and fell onto the floor, which resulted in C2 sustaining injuries that required medical attention. " Bruising swelling to the right periorbital area with localized tenderness extending to the right maxillary. Right forehead tenderness" The Licensee also admitted in interview that she did not report the incident to the department as required after knowing a child in care sought medical attention from an injury sustained while in care. Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited. See LIC809 D.

LPA Shannan Williams informed licensee, Cinthya Gomez, that this report dated 9/8/2025 documents one (1) Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Shannan Williams informed the licensee to provide a copy of this licensing report dated 9/4/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification
NAME OF LICENSING PROGRAM MANAGER: Cynthia Biszant
NAME OF LICENSING PROGRAM ANALYST: Shannan Williams
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/08/2025 02:27 PM - It Cannot Be Edited


Created By: Shannan Williams On 09/05/2025 at 01:54 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GOMEZ, CINTHYA FAMILY CHILD CARE
FACILITY NUMBER: 376628572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2025
Section Cited
CCR
102416.2(b)(1)

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(b) The licensee shall report to the Department any of the events...that occur during the operation of the family child care home. That require...
(1) Medical treatment means treatment by a medical professional...
This requirement is not met as evidenced by:
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The Licensee stated she will contact the duty line no less than one business day after finding out a child in care received medical treatment due to any injuries sustained or potentially sustatained while in care and also will report to the department in writing via UIR no more than 5 business days of the incident.
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Based on Licensee admittance and interview, the licensee did not comply with the section cited above. The Licensee stated she recieved notification that a child who was injured in care received medical treatment and it was not reported to the Department. This is a potential risk to the health, safety or personal rights risk to persons in care.
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Licensee will contact the duty line at 619-767-2248 to report via telephone and email SDincidentreports@dss.ca.gov

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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.
Cynthia Biszant
NAME OF LICENSING PROGRAM MANAGER:
Shannan Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2025 02:27 PM - It Cannot Be Edited


Created By: Shannan Williams On 09/05/2025 at 03:48 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GOMEZ, CINTHYA FAMILY CHILD CARE
FACILITY NUMBER: 376628572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2025
Section Cited
CCR
102432(a)(2)

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(a) Each child receiving services from a family child care home shall have certain rights... These rights include, but are not limited to, the following:..(2)To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement is not met as evidenced by:
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The Licensee stated she will not let any children play in non-age appropriate equipment, including, but not limited to, an infant crib in the tuture. The Licensee stated she will fill the crib with bean bag chairs when the crib is not being used for sleep.

CHECK ALL DATES/TIMES/SIGNATURES/CLEAR POCS!!!
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Based on interview and record review the Licensee did not comply with the section cited above by allowing two children to play in an infant crib which resulted in a child sustaining a serious injuries, which posed an immediate health and safety risk to children in care.
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The Licensee will submit to LPA S. WIlliams a signed document stating she will not allow daycare children to play in the infant crib or in other equipment that is not meant for play or is not age appropritate.

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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.
Cynthia Biszant
NAME OF LICENSING PROGRAM MANAGER:
Shannan Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GOMEZ, CINTHYA FAMILY CHILD CARE
FACILITY NUMBER: 376628572
VISIT DATE: 09/08/2025
NARRATIVE
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A notice of site visit was given to the Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the Licensee, Cinthya Gomez.

Exit interview was conducted with Licensee, Cinthya Gomez and a copy of this report, Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Cynthia Biszant
NAME OF LICENSING PROGRAM ANALYST: Shannan Williams
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC809 (FAS) - (06/04)
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