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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416067
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:06:59 PM

Document Has Been Signed on 01/06/2023 04:06 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LOPEZ, VANESSAFACILITY NUMBER:
354416067
ADMINISTRATOR:VANESSA LOPEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 537-5730
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 2DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Vanessa LopezTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Vanessa Lopez for a case management visit. Present were licensee, licensee's husband and two day care children. Licensee's 12 year old son arrived a short while later.

During visit, LPA observed four children were missing off of children's roster. LPA did not observe any other violations.

The following type B deficiency was cited on the attached page (809-D). Licensee was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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 2
Document Has Been Signed on 01/06/2023 04:06 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 01/06/2023 at 03:21 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LOPEZ, VANESSA
FACILITY NUMBER: 354416067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited
CCR
102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by LPA observed four children were missing off of children's roster.
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Licensee will submit a current roster to CCLD by POC date.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023


LIC809 (FAS) - (06/04)
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