<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500171
Report Date: 10/10/2022
Date Signed: 10/10/2022 05:49:24 PM

Document Has Been Signed on 10/10/2022 05:49 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: 19CENSUS: 9DATE:
10/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Ma Natividad GonzalesTIME COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On Monday, October 10th, 2022, Licensing Program Analysts (LPA) Elvira Sierra conducted a Case Management inspection and met with Licensee, Ma Natividad Gonzalez. LPA observed there were currently nine children in care with the Licensee and Licensee's husband.

LPA learned through interviews that Licensee's adult son (A1) transport a child on 08/12/22 and does not have fingerprint clearance on file with Licensing. Licensee stated that her son, does not live in the home since 08/15/22 and does not provide assistance with the daycare children anymore. LPA advised that all adults living or working in the home over the age of 18 must be fingerprint cleared. Also, Licensee was advised that a current roster of children who are provided care in the facility shall be maintain. LPA received an incomplete roster on 08/18/22.

Deficiencies were cited on subsequent page 809D. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC 809 D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. Exit interview was conducted. LIC 9224 and Appeal Rights were reviewed and provided to Licensee, Ma Natividad Gonzalez.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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 3
Document Has Been Signed on 10/10/2022 05:49 PM - It Cannot Be Edited


Created By: Elvira Sierra On 10/10/2022 at 04:09 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2022
Section Cited
CCR
102370(d0(1)

1
2
3
4
5
6
7
102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department.
1
2
3
4
5
6
7
Licensee stated that her son is not longer living in the home and not longer assist with the children.
8
9
10
11
12
13
14
his requirement was not met as evidence by; LPA received information during parent interviews that her unfingerprinted son (A1) was helping with trasnporting daycare children. This is a requirements that if not corrected poses an immediate risk to the health and safety of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/10/2022 05:49 PM - It Cannot Be Edited


Created By: Elvira Sierra On 10/10/2022 at 04:12 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: GONZALEZ, MA NATIVIDAD
FACILITY NUMBER: 394500171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2022
Section Cited
CCR
102417(8)

1
2
3
4
5
6
7
102417 Operation of a Family Child Care Home 8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidence by; LPA received an incomplete roster from Licensee.
1
2
3
4
5
6
7
Licensee stated that she will make sure that she will maintain an updated roster. LPA received a new update roster during inspection visit. Deficiency cleared and corrected.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3