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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406583
Report Date: 01/12/2022
Date Signed: 01/12/2022 03:51:01 PM

Document Has Been Signed on 01/12/2022 03:51 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:CARRENO, ROSAFACILITY NUMBER:
434406583
ADMINISTRATOR:CARRENO, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 259-5536
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Rosa CarrenoTIME COMPLETED:
04:00 PM
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On 01/12/2022 at 03:35 PM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Rosa Carreno, for a case management visit.

LPA observed the TSO sign was still posted at the front entrance. LPA was granted access to the facility by licensee's son. LPA observed licensee and husband in the facility. LPA informed licensee the reason for the visit. LPA did not observe any children at the facility, licensee stated they had not been watching children since the TSO was served in November.

Exit interview conducted and report was reviewed in Spanish with the licensee, Rosa Carreno. A notice of site visit was given and must remain posted for 30 days
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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