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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376626037
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:43:16 AM

Document Has Been Signed on 06/07/2024 11:43 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GOMEZ, SILVIA FAMILY CHILD CAREFACILITY NUMBER:
376626037
ADMINISTRATOR/
DIRECTOR:		SILVIA GOMEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 224-7152
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Silvia GomezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On date and time listed, Licensing Program Analyst (LPA) William Chancellor arrived unannounced to conduct a Case Management Visit in response to an Unusual Incident Report (UIR) received by Community Care Licensing (CCL) on May 17, 2024. The incident involved a child kicking a family pet and no medical attention being required to the child.

Documents relevant to the UIR were provided and confidential interviews were conducted with Licensee and two assistants.

LPA has determined that the facility acted appropriately, and no violations have been identified. Parents were immediately notified, an Ouch Report was provided, Licensee immediately called LPA and documented a UIR to CCL. LPA has determined this to be a random isolated incident where the family pet was injured, and the child was not. No other occurrences have occurred prior or since this isolated incident. Licensee took immediate action separating the child and implementing redirective strategies to ensure the safety of the children and family pet. Licensee also included kindness activities and children’s books into circle time, to support the children on the topic.

Based on the information gathered, there appears to be no violations of Title 22 Regulations found at this time, and therefore, there were no deficiencies cited during this inspection.

An exit interview was conducted, and a copy of this report was provided to Licensee Silvia Gomez. A Notice of Site Visit must be posted for 30 consecutive days.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: William M Chancellor Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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