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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500666
Report Date: 10/10/2022
Date Signed: 10/10/2022 01:41:20 PM

Document Has Been Signed on 10/10/2022 01:41 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GONZALES-GRAY, DENYSEFACILITY NUMBER:
394500666
ADMINISTRATOR:GONZALES-GRAY, DENYSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 981-5736
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:licensee, Denyse Gonzales-GrayTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Lauren Scott met with Licensee, Denyse Gonzales-Gray for the purpose of conducting a change of location inspection. Licensee is requesting a change of location from old facility with license #393622222 to current location. The facility is a one story home that consists of 3 bedrooms, and 2 bathrooms. LPA and Licensee toured the entire home inside and outside. Off limit areas consist of the master bedroom/ bathroom, back bedroom, front bedroom, garage and backyard. Licensee acknowledged that children are never allowed in the off limit areas. Off limit areas will remain inaccessible by door handle covers, locked closed doors and supervision. All adults living and working in the facility have a criminal record clearances. Licensee understands that 100% supervision is required when children play in the backyard and any unfenced areas.

LPA discussed licensing requirements with Licensee including the posting of licensing inspection notices and reports, as well as injury and incident reporting. Fire extinguisher and first aid kit is located in the kitchen. Smoke alarm and carbon monoxide detectors were observed to be in operational order. Licensee stated there are no weapons in the home. There is a fenced in pool in the backyard. The fenced pool does not have a proper self-closing gate, so the backyard will be off limits until cleared by an LPA. LPA observed a fireplace that was appropriately barricaded and non-operational. Hazardous items and personal hygiene items are made inaccessible to children. Sharp utensils are stored in out of reach cabinet in the kitchen.

Licensee has a current Mandated Reporter Training Certificate that expires 10/2024. Current pediatric CPR and first aid training was verified and expires 03/2023. LPA discussed new safe sleep regulations. In addition, LPA discussed the infant sleep regulations with licensee. LPA discussed the requirement to check and log infant napping every 15 minutes for infants 24 months and under. LPA provided a copy of LIC 9227 Individual Sleeping Plan, for infants under 12 months, for licensee during today's inspection.

Report Continues on 809-C...
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
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)
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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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GONZALES-GRAY, DENYSE
FACILITY NUMBER: 394500666
VISIT DATE: 10/10/2022
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Licensee currently does not have any children enrolled that require IMS. LPA discussed IMS services and the requirement to create a plan of operation. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Licensee understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Licensee understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Licensee understands that if any structural changes are made to the home; licensing must be notified prior to construction. Licensee understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Licensee understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years.

This facility evaluation report was reviewed and discussed with the Licensee. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Licensee was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of today, Licensee will be approved for a Large Family Child Care Home license for a capacity of 12 children with no more than 4 infants, or up to 14 children with no more than 3 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
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
LIC809 (FAS) - (06/04)
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