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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417267
Report Date: 03/19/2025
Date Signed: 03/19/2025 11:44:17 AM

Document Has Been Signed on 03/19/2025 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GOMEZ GARCIA FAMILY CHILD CAREFACILITY NUMBER:
197417267
ADMINISTRATOR/
DIRECTOR:		GOMEZ GARCIA, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 453-6316
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:ANA GOMEZ GARCIA,LICENSEETIME VISIT/
INSPECTION COMPLETED:
12:00 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 03/19/2025 Licensing Program Analyst (LPA) Lisa Clayton arrived at the Gomez Garcia Family Child Care Home unannounced, to conduct a Case Management – Incident inspection to follow up on an Unusual Incident received in the Department by mail. LPA Clayton was greeted by assistant Mirella Marquez and Licensee Ana Gomez Garcia. LPA Clayton observed 11 children in care being supervised and cared for by 3 fingerprint cleared staff.

INCIDENT DETAIL: on March 4 around 10:55am the children were playing on the slide and C1 was about to slide down he tripped, flipped and rolled down the slide and we noticed that his lip was bleeding and teacher Corina took him inside and cleaned his lip applied ice and called mom and let her know what happened. Mom asked if he was ok and we said yes. His grandmother picked him up around 5:10 – 5:15p, but I was already gone for the day. Marisol and Corina were here. The next day (03/05/2025) mom came in the morning, and she told me that when he fell, he hit his tooth and that she was taking him to the dentist that day. She picked him up early and took him to the dentist. I told her that when he fell, he wasn’t complaining about his tooth, only his lip. He returned to day care on March 11, 2025. Mom gave me the receipt that showed his tooth was pulled. We called the insurance company and filed a claim.



During today's visit LPA Clayton met and talked to C1. LPA also observed C1 sliding down the slide. LPA also provided best practices regarding the play structure.

Based on the information obtained and observations of the play yard area, C1 was using the slide as intended and tripped at the top of slide, falling down the slide, bumping his lip and front tooth. As a result, his tooth was removed on March 5, 2025. C1 returned to the day care on March 11, 2025 with no restrictions. The facility had appropriate children/staff ratios during the incident, there were no equipment or objects on the Play structure when C1 fell.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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 3
Document Has Been Signed on 03/19/2025 11:44 AM - It Cannot Be Edited


Created By: Lisa Clayton On 03/19/2025 at 10:04 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOMEZ GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 197417267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
102416.2(b)(3)(B)

1
2
3
4
5
6
7
(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code..... that occur during the operation of the family child care home. (3)Health and Safety Code Section 1597.467(b)(1) provides in part: "A report shall be made to the Department… any of the following events: (B) Any injury to any child that requires medical treatment.
1
2
3
4
5
6
7
Licensee and staff will ensure that all unsual incidents are reported to the Department via phone within 24 hours of the occurence and a written report is submitted to the Department within 7 days of the occurence.
8
9
10
11
12
13
14
This requirement wa not met as evidenced by LPA Clayton observation that the licensee never contacted the department by phone to report the incident, and the written report was emailed to the Department 14 days after the occurence.
8
9
10
11
12
13
14
 LPA Clayton reviewed the LIC 624B with Licensee and her assistant and LPA provided Licensee with a copy of the form. Both Licensee and her assistant acknowledged understanding.

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:Karren Starks
LICENSING EVALUATOR NAME:Lisa Clayton
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GOMEZ GARCIA FAMILY CHILD CARE
FACILITY NUMBER: 197417267
VISIT DATE: 03/19/2025
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
26
27
28
29
30
31
32
Because the incident was not reported in the time frame required by Title 22 Regulations, Deficiencies are cited today (see LIC 809-D).

A notice of site visit was given and posted for 30 days. Exit interview conducted and report was reviewed with Ana Gomez Garcia.

LPA Clayton posted Notice of Site visit which to the remain posted for 30 days.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3