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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500087
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:15:49 AM

Document Has Been Signed on 07/22/2022 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GOMEZ GONZALEZ, CLAUDIAFACILITY NUMBER:
394500087
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Claudia Gomez GonzalezTIME COMPLETED:
11:30 AM
NARRATIVE
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LPA Erwin Tjhia and LPM Bettina Engelman met with the licensee, Claudia Gomez Gonzalez for case management inspections.

Upon arrival at the facility at 9:30 am, licensing staff observed a minor in the home caring for 1 day care child and minor children who reside in the home. There was no other adult present in the home at that time. The licensee was away from the home and arrived at 10:15 am. Due to the minor caring for a day care child, a TYPE A DEFICIENCY was cited today.

Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 9099-D in each child's file.

Appeal Rights were provided, and LPA posted a Notice of Site Visit which must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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 07/22/2022 11:15 AM - It Cannot Be Edited


Created By: Erwin Tjhia On 07/22/2022 at 10:51 AM
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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GOMEZ GONZALEZ, CLAUDIA
FACILITY NUMBER: 394500087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
102417(a)

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(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence.
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Licensee stated that she had appoinment to attend to when a parent dropped off a child. Licensee could not cancel her appoinment. Licensee understood that she can not leave a minor to care for the day care child when no adult is present at the home.
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This requirement was not met as evidenced by: licensing staff observed a minor in the home caring for 1 day care child and minor children who reside in the home. There was no other adult present in the home at that time. The licensee was away from the home
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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:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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