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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500999
Report Date: 02/03/2026
Date Signed: 02/03/2026 06:56:57 PM

Document Has Been Signed on 02/03/2026 06:56 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DOUGLASS, KATHERYNE & GOMEZ, KARENFACILITY NUMBER:
394500999
ADMINISTRATOR/
DIRECTOR:		DOUGLASS, KATHERYNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 513-0576
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
02/03/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Katheryne DouglassTIME VISIT/
INSPECTION COMPLETED:
07:05 PM
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On February 3, 2026, at 12:32 PM, Licensing Program Analysts (LPAs) Deborah Khashe and Denice Pablico met with licensee, Katheryne Douglass for the purpose of an unannounced annual inspection. The purpose of the visit was explained and the entrance checklist was provided. During today’s inspection there were three (3) children present. Licensee's operating hours are 7:00 AM. to 6:00 PM. Monday through Friday. Meals provided to children include breakfast, AM snack, lunch, and PM snack. Drinking water is provided to day-care children. LPA noted that licensing fees are currently due.

All adults subject to criminal background review have obtained criminal record clearance. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

A health and safety inspection was conducted inside and outside of the FCCH. Licensee accompanied LPA for the entirety of the tour. The FCCH is single story house that consists of Living room, family room, den, kitchen, laundry room, 4 bedrooms, 3.5 bathrooms, laundry room and a two- car garage. LPA verified that toxic and hazardous items were inaccessible to children in care. The backyard is fenced but applicant does not plan to use it. There is a pool in the back yard, which is surrounded by a 5ft wrought iron fence. There is one entry for the fencing that currently does not self-close. In addition, there is patio door from an off-limit bedroom suite that leads directly to the pool area. There is a 5 ft. wrought iron fence around the patio door with a gate that meets regulations that makes the body of water inaccessible from the bedroom suite. Applicant plans to use the unfenced front yard for children’s outside play space, and she understands that 100% supervision is required in unfenced areas. Applicant stated there are no firearms in the home.

Report continues on LIC809-C... (Page 2)

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Deborah Khashe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999
VISIT DATE: 02/03/2026
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Licensee stated she has a dog in the home. The Off-limits areas of the FCCH are all bedrooms, living room, laundry room, the backyard and the garages. Licensee understands that OFF-limit areas must remain inaccessible to children in care.

LPA observed a functioning smoke detector and carbon monoxide. LPA observed cleaners stored in the garage and laundry room which are designated as off limit areas. LPA observed knives stored in the kitchen and are inaccessible to children.

Children's files were reviewed. Emergency information and required immunization records were not on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. Last fire drill was not conducted on 2/2/2026. Licensee's immunization records are available in the facility file. Licensee, Katheryne Douglass currently does not have current Pediatric First Aid or Mandated Reporter Training. Certifications on file have expired.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LPA discussed the requirement to check and log infant napping every 15 minutes, for infants under 24 months. LPA provided a copy of LIC 9227 Individual Infant Sleeping Plan, for infants under 12 months.

LPA discussed the Year-Round/Daily Reminder of Water Safety Requirements and Measures with licensee. LPA provided licensee the PIN 23-17-CCLD, the Year-Round and Daily Reminder of Water Safety Requirements and Measures. LPA discussed with Licensee the importance of checking for bodies of water on the premise daily prior to children’s arrival for children’s safety.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Report continues on LIC809-C...(Page 3)

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Deborah Khashe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999
VISIT DATE: 02/03/2026
NARRATIVE
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( Page 3)
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. Applicant 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. Applicant 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. Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years.

During the exit interview, the LICENSEE, Katheryne Douglass confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22- 02-CCP. 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: https://www.ada.gov/resources/child-care-centers/

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community- care-licensing/subscribe and select the Child Care option to receive email communication.

Report Continues on LIC 809 C... (page 4)

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Deborah Khashe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999
VISIT DATE: 02/03/2026
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Exit interview conducted and report was reviewed with the licensee, Katheryne Douglass. Appeal rights and a notice of site visit were provided. A notice of site visit was posted and must remain posted for 30 days. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, LPA Khashe and Pablico informed licensee, Katheryne Douglass that this report dated (02/03/2026) documents four (4) Type B citations during today’s inspection.

In the areas that were evaluated today, LPA Khashe and Pablico informed licensee, Katheryne Douglass that this report dated 02/03/2026 documents one (1) type A citation during today's inspection.

Also, LPA Khashe and Pablico informed licensee, Katheryne Douglass to provide a copy of this licensing report dated 02/03/2026 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Deborah Khashe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/03/2026 06:56 PM - It Cannot Be Edited


Created By: Deborah Khashe On 02/03/2026 at 05:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.814(a)(1)(A)(i)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (A) An enclosure, including, but not limited to, a fence, wall, or other barrier that isolates the swimming pool from access to the family daycare home and has all of the following characteristics: (i) An access gate that opens away from the swimming pool and is self-closing with a self-latching, key lockable device placed no lower than 60 inches above the ground.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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Licensee, Katheryne Douglass agrees to have the gate fixed so it self closes after it is opened.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Deborah Khashe
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2026 06:56 PM - It Cannot Be Edited


Created By: Deborah Khashe On 02/03/2026 at 05:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee, Katheryne Douglass will submit a copy of Infant Sleep napping logs to LPA Khashe by 3//3/ 26 via email.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2026
Plan of Correction
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Licensee, Katheryne Douglass will complete the Mandated Reporter Training and send a copy of certification to LPA Khashe via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Deborah Khashe
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2026 06:56 PM - It Cannot Be Edited


Created By: Deborah Khashe On 02/03/2026 at 05:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN
FACILITY NUMBER: 394500999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2026
Plan of Correction
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2
3
4
Licensee, Katheryne Douglass will submit proof of completion of Pediatric CPR and First Aid by POC due date.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 files child files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2026
Plan of Correction
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2
3
4
Licensee, Katheryne Douglass will submit proof of immunization on the CPDH 286 and submit to LPA Khashe by POC due
date. 03/03/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Deborah Khashe
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


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