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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021105
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:10:33 PM

Document Has Been Signed on 06/15/2023 02:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GONZALEZ FAMILY CHILD CAREFACILITY NUMBER:
198021105
ADMINISTRATOR:GONZALEZ, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 652-9723
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
06/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Elizabeth GonzalezTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Judy Mora conducted a case management inspection due to an incident that occurred on 03/08/23. LPA met with Licensee, Elizabeth Gonzalez, who guided LPA on a tour of the home. LPA conducted interview and obtained a copy of the facility roster. Visit was conducted in Spanish.

The incident that occurred on March 8, 2023 was reported to the Department on March 8, 2023, within the required 24 hours.

Based on all information obtained on this date, and interview conducted, no follow-up is necessary regarding the incident. The incident was previously addressed.

Licensee inquired about being sent a new facility license. LPA printed a copy for Licensee.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

Exit interview was conducted with Licensee, Elizabeth Gonzalez. Appeal rights explained & provided.

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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