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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500171
Report Date: 04/06/2022
Date Signed: 04/15/2022 04:55:43 PM

Document Has Been Signed on 04/15/2022 04:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GONZALEZ, MA NATIVIDADFACILITY NUMBER:
394500171
ADMINISTRATOR:GARCIA, NATIVIDADFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 642-3525
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 20CENSUS: 15DATE:
04/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ma Natividad GonzalezTIME COMPLETED:
02:30 PM
NARRATIVE
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This is an amended report.
On Wednesday, April 06, 2022, Licensing Program Analyst (LPA) Elvira Sierra and Licensing Program Manager (LPM) Bettina Engelman conducted an unannounced Case Management visit and met with Licensee Assistant, Briana Roman. Upon arrival present in the facility were 11 children (5 infants, 5 preschool and one school age) being supervised by Licensee’s Assistant. Licensee and 4 more children arrived later during the inspection.

LPA conducted an inspection in all areas accessible to children. LPA observed licensee was not operating within her licensed capacity and was exceeding the required limitations. Also, stairs leading to the second floor were not barricaded accessible to children. There were children present under age 5 and awake. LPA observed an infant sleeping in a twin feeding chair covered with a blanket.

Based on observations during the inspection the following deficiencies listed on the attached LIC 809D are being cited in accordance with Health and Safety and California Code of Regulations Title 22.

Upon receipt of this report, the Licensee shall post the Notice of site visit and any licensing report documenting type “A” deficiency. The report and the Notice of site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided ti the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of a any newly enrolled children for the next 12 months (1 year). The acknowledgement form must be maintain in each child’s file immediately upon receipt from parent. Licensee was provided a copy of the parent Acknowledgment of receipt of Licensing Reports Form during this visit.

Appeal of Rights and Notice of Site Visit was provided. Exit interview conducted and report was reviewed with the Licensee, Ma Natividad Gonzalez.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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Document Has Been Signed on 04/15/2022 04:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/08/2022 09:09 AM


Created By: Elvira Sierra On 04/06/2022 at 02:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
HSC
1597.465

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This is an amended report.
§1597.465 Large family day care homes; number of children. A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met.....This requirement was not met as evidence by: Upon arrival LPA observed 11 children in care with one staff. Licensee and 4 more children arrived during the inspection. Present were 5 infant, 7 preschool and 3 school age. This is a deficiency that if not corrected pose an immediate risk to the health and safety of the children in care.
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Licensee agree that she will submit a written plan of correction on how she will maintain capacity limitation by the due date. LPA will conduct a return visit to verified correction.
Type A
04/07/2022
Section Cited
CCR
102425(a)

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102425 Infant Safe Sleep (a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement was not met as evidence by; LPA observed one sleeping infant in chair covered with a blanket. This is a deficiency that if not corrected pose an immediate risk to the health and safety of the children in care.
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Licensee stated she will submit a written plan of correction on how to comply with safe sleep regulations by the due date.
Type A
04/07/2022
Section Cited
CCR102417

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102417 Operation of a Family Child Care Home. (3) Where children less than five years old are in care, stairs shall be fenced or barricaded. This requirement was not met as evidence by' LPA observed stairs leading to the second floor accessible to children. Present were children awake and under 5 years old. This is a deficiency that if not corrected pose an immediate risk to the health and safety of the children in care.

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Licensee will submit of proof of correction by the due date.

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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:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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