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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629375
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:33:31 PM

Document Has Been Signed on 12/07/2023 02:33 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:HERNANDEZ, GLORIA ZAMAYOA FAMILY CHILD CAREFACILITY NUMBER:
376629375
ADMINISTRATOR:GLORIA ZAMAYOAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 743-9132
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH: TIME COMPLETED:
02:40 PM
NARRATIVE
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On 12/7/23 at 12:30 pm, Licensing Program Analyst (LPA) Daniela Huerta, made an unannounced visit for the purpose to follow up on an incident that occurred on 04/01/2023. The licensee failed to report an incident that occurred at the facility with twenty-four hours of the incident and failed to submit an LIC 624B – Unusual Incident Report within seven days to the department. See LIC 809D page for the deficiency cited. There were five (5) children present during the inspection.

LPA interviewed the licensee. The LPA was unable to interview children due to the children sleeping. The LPA and licensee discussed the reporting requirements and the LPA provided the licensee with the email (SDIncidentReports@dss.ca.gov) where she can submit the LIC 624B. The LPA obtained a copy of the facility roster. The licensee will complete an LIC 624B – Unusual Incident Report and provided a copy to the LPA.

An exit interview was conducted, and the report was reviewed with the Licensee, Gloria Zamayoa Hernandez. The licensee was provided a copy of their appeal rights (LIC9058), Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00.

SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Daniela Huerta
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/07/2023 02:33 PM - It Cannot Be Edited


Created By: Daniela Huerta On 12/07/2023 at 01:47 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: HERNANDEZ, GLORIA ZAMAYOA FAMILY CHILD CARE
FACILITY NUMBER: 376629375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
102416.2(b)

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102416.2(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. This requirement was not met as evidence by:
Based on the interview and records review, the Licensee did not report the incident which occurred on 04/01/23 at the licensed facility. Licensee stated she was unaware that she was supposed to report the incident to the Department due to the incident occurring afterhours. This poses a potential health and safety.
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The LPA reviewed the 102416.2(b) regulation, and Unusual Incident Report – LIC 624B with the licensee. The licensee will watch the Child Care Reporting Requirements: https://ccld.childcarevideos.org/family-child-care-providers/child-care-reporting-requirements/
The Licensee will provide a written summary to the LPA no later than 12/14/2023.

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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:Jason Garay
LICENSING EVALUATOR NAME:Daniela Huerta
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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