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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566217370
Report Date: 04/15/2025
Date Signed: 04/15/2025 03:04:36 PM

Document Has Been Signed on 04/15/2025 03:04 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
566217370
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
04/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Adelina GonzalezTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On April 15, 2025 at 11:15 AM, Licensing Program Analyst (LPA) Laura Carone conducted an unannounced Annual/Random inspection. LPA informed the licensee, Adelina Gonzalez of the purpose of the inspection and together toured the facility inside and outside. Licensee was caring for 8 children at the time of the inspection. Licensee is requesting a capacity increase to a large license. Fire clearance was granted on 03/12/2025 with no restrictions.

Licensee was caring for 4 infants, 2 preschool,, and 2 school aged children. Licensee is over capacity for a small child care license. LPA reviewed and provided licensee with a capacity chart. Resident was caring for the infants. Resident has fingerprint clearance and TB test, but none of the requirements to be an assistant. Licensee stated that Resident helps her with her own children. Resident is pregnant and due June 2025, adding another infant to the household. Licensee has twin infants. During tour,.Licensee's child (C6) opened accessible bedroom door and went inside. LPA observed an infant (C8),licensee's child, on a swing in the bedroom that had the door closed. LPA informed licensee that the door to the bedroom where an infant is present needs to be open and licensee should be able to visually observe infant. LPA observed infant (C7) in a playpen with a bottle and a stuffed animal. Licensee does not have completed Infant Sleep Charts documenting 15 minute checks for the infants in care. Licensee stated that she throws them out when complete. LPA observed only 2 playpens for 4 infants. Licensee stated that all infants are not always present at the same time. LPA observed an infant car seat with a blanket laying on top in living room. Licensee explained that a parent leaves the car seat because she car pools to work. LPA advised licensee to keep the Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Laura Carone
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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 9
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370
VISIT DATE: 04/15/2025
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car seat in an area that is not used for child care. The home is a 4- bedroom, 2 -bathroom, single story home. The licensee will use the living room, kitchen, hall bathroom, and backyard for the childcare. Inaccessible areas should be garage, 4-bedrooms, and 1-bathroom as listed in facility sketch as designated area off limits for childcare. The 4 bedrooms and off limits bathroom were unlocked and accessible to the children in care. LPA explained that the areas not to be used for child care should be made inaccessible during child care hours. The backyard is fully enclosed with a fenced wall. LPA did not observe any toxins/hazardous items accessible to children in the facility today. Cleaning agents and disinfectants are stored in the garage making them inaccessible. Kitchen knives are stored out of reach of children. The bathroom to be used for children in care was observed to be clean and free of toxins/hazardous items accessible to children. A small dog is in the home with current immunizations.

A regulation 2A10BC fire extinguisher was observed with a purchase date of 01/04/2025. Licensee is reminded to service or purchase the fire extinguisher yearly. The City of Oxnard Fire Department inspected and tested smoke and carbon monoxide detectors in the home on 03/12/2025 which were found operational. All adults in the home are fingerprint cleared. LPA observed the home to be orderly. No bodies of water were observed on site. Licensee stated that there are no guns or ammunition in the home.

Licensee's Pediatric First Aid/CPR certificate is valid until 04/08//2027. Licensee's Mandated Reported Training is valid until 03/26//2027. Licensee provided proof of control of property with a rental agreement and submitted a signed Landlord Consent Form LIC9149. Licensee last completed an emergency disaster drill on 12/01/2024. All required forms including Notification of Parent's Rights are prominently posted for parent's or authorized representative to view. A roster of children in care was observed current and almost complete. Licensee's own children are not listed. All children records were reviewed, and LPA observed incomplete Identification and Emergency Notification forms (LIC 700) and not all children had a copy of immunization record on file. There were no child files for licensee's 6 children.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at


Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Laura Carone
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370
VISIT DATE: 04/15/2025
NARRATIVE
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www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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.



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/.

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-andresources/
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.

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.

During the exit interview, the licensee, Adelina Gonzalez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A large child care license is not granted today due to 4 Type A and 4 Type B deficiencies cited. The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. Appeal rights were given LIC9058. LPA Laura Carone informed licensee, Adelina Gonzalez that this Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Laura Carone
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370
VISIT DATE: 04/15/2025
NARRATIVE
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report dated 04/15/2025 documents 4 Type A citations which shall be posted for 30 consecutive days. As this is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Laura Carone informed the licensee to provide a copy of this licensing report dated 04/15/2025 that documents any Type A citation 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.

Exit interview conducted with licensee, Adelina Gonzalez. The report was reviewed and a copy was given.
Visit was conducted in Spanish.
NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Laura Carone
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/15/2025 03:04 PM - It Cannot Be Edited


Created By: Laura Carone On 04/15/2025 at 01:50 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above in 2 out of 2 persons, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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2
3
4
LPA observed a bottle in 2 infants playpens and a stuffed animal next to one of the infants. LPA asked licensee to remove the items. Licensee removed the bottles and the stuffed animal.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

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 in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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2
3
4
LPA observed an infant in a bedroom (that was not supposed to be accessible to the children) with the door closed. LPA informed licensee that the door needs to stay open when an infant is in the room.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Laura Carone
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/15/2025 03:04 PM - It Cannot Be Edited


Created By: Laura Carone On 04/15/2025 at 01:50 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(5)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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3
4
LPA observed an infant in a bedroom (that was not supposed to be accessible to the children) with the door closed. LPA informed licensee that the door needs to stay open when an infant is in the room. Licensee will visually supervise infants.
Type A
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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4
LPA observed 8 children in care: 4 infants, 2 preschool aged, and 2 schoolaged children present. 3 other school aged children that live in the home with not present at the time of the inspection. Licensee will terminate 2 infants immeditely. Licensee will email LPA the names of the infants that will be disenrolled from child care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Laura Carone
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/15/2025 03:04 PM - It Cannot Be Edited


Created By: Laura Carone On 04/15/2025 at 01:50 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
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 is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 4 objects which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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2
3
4
Licensee can only have 2 infants when there is a capacity of 8 children in care. Licensee will terminate services for 2 infants.
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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2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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2
3
4
Licensee will immediately complete 15 minute check logs for infants in care and submit proof to LPA via email:laura.careone@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Laura Carone
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/15/2025 03:04 PM - It Cannot Be Edited


Created By: Laura Carone On 04/15/2025 at 01:50 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GONZALEZ FAMILY CHILD CARE
FACILITY NUMBER: 566217370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 8 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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2
3
4
Licensee will have parents of children that have tthe emergency information card to complete and sign. 4 child files have incomplete forms and no signature. Licensee will send copies of the completed documents via email: laura.carone@dss.ca.gov
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
1
2
3
4
Licensee give parents of all children in care a copy of the emergency information card to complete and sign. Licensee will send copies of the completed documents via email at:laura.carone@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Susana Martinez
NAME OF LICENSING PROGRAM MANAGER:
Laura Carone
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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