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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573621622
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:09:42 PM

Document Has Been Signed on 02/15/2024 04:09 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:GOMEZ VAZQUEZ, LETICIAFACILITY NUMBER:
573621622
ADMINISTRATOR:GOMEZ VAZQUEZ, LETICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 757-9136
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leticia Gomez VazquezTIME COMPLETED:
11:30 AM
NARRATIVE
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Leticia Gomez Vazquez, is Spanish speaking and Licensing Program Analyst (LPA) Corina Beckby spoke with Licensee in Spanish and translated the conversation to English below.

On 02/15/24 Licensing Program Analyst (LPA) Corina Beckby, conducted an unannounced annual inspection and met with Licensee, Leticia Gomez Vazquez. LIC (126), Entrance Checklist for Family Child Care Homes, was provided and reviewed with Licensee. Present in the facility was Licensee and assistant supervising 6 children including 2 infants (ages: 2 yrs, 2 yrs, 2 yrs, 4 yrs, 20 months, and 23 months). Facility hours of operation are Monday – Friday from 7:00 am – 6:00 pm. LPA verified that annual fees are current.

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 in all areas accessible to children. Upon entry, LPA observed the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights. Off-limits areas include 2 bedrooms (master and daughters), garage and shed in backyard. Off-limits areas will remain inaccessible to children by closed doors, gates, and/or supervision. The licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa. Toys appear to be safe and in working order.
Report continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 02/15/2024 04:09 PM - It Cannot Be Edited


Created By: Corina Beckby On 02/15/2024 at 10:27 AM
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: GOMEZ VAZQUEZ, LETICIA
FACILITY NUMBER: 573621622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 in that 2 of 3 children's records reviewed were missing vaccine records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee will email LPA Beckby copies of the vaccines missing, by due date.
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
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 childrfen's records reviewed did not have consent medical forms signed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee will email copies of signed consent forms by due date to LPA Beckby.
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:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2024 04:09 PM - It Cannot Be Edited


Created By: Corina Beckby On 02/15/2024 at 10:27 AM
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: GOMEZ VAZQUEZ, LETICIA
FACILITY NUMBER: 573621622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

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 in 3 out of 3 children's records reviewed did not have signed Liability Insurance forms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee will email signed Liability forms to LPA Beckby by due date.
Section Cited
Deficient Practice Statement
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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.
SUPERVISOR'S NAME:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


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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: GOMEZ VAZQUEZ, LETICIA
FACILITY NUMBER: 573621622
VISIT DATE: 02/15/2024
NARRATIVE
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Cleaning agents and detergents are made inaccessible to children. Poison, toxic and hazardous times are made inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home and meet Title 22 regulations. LPA observed a 2A10BC fire extinguisher. Sharp utensils are inaccessible to children. Licensee understands that she must ensure the safety locks are not broken. The backyard is fenced. Licensee states there are no weapons in the home.

LPA observed a current roster and fire drill log. LPA reviewed 3 children’s files. Preventative health and current pediatric CPR and first aid training was verified for Licensee, and CPR expires 05/23/25. Mandated Reporter Training certificate expires: 03/17/25. Licensee’s Mandated reporter could not be verified. Licensee understands the training must be completed once every two years, and training is accessible at www.mandatedreporterca.com.

Licensee currently has no children enrolled that require IMS. Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department. 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 has 2 infants currently enrolled. Licensee is maintaining sleep logs for all infants in care (under 24 months) and Infant Individual Sleeping Plan for infants under 12 months. LPA discussed the safe sleep regulations with Licensee and provided 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.
Report continued on LIC809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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: GOMEZ VAZQUEZ, LETICIA
FACILITY NUMBER: 573621622
VISIT DATE: 02/15/2024
NARRATIVE
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LPA encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

During the exit interview, the Licensee, Leticia Gomez Vazquez, confirmed there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California. LPA reminded Licensee to advise the department of any and all facility closures (vacations, Holidays, and illness).

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 www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

LPA informed Licensee, Leticia Gomez Vazquez, that this report dated 02/15/24, documents Type B citations that are a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for the deficiency.

An Exit interview was conducted, and the report was reviewed with Licensee, Leticia Gomez Vazquez. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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