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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406583
Report Date: 04/18/2022
Date Signed: 04/18/2022 12:08:21 PM

Document Has Been Signed on 04/18/2022 12:08 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:
04/18/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosa CarrenoTIME COMPLETED:
12:15 PM
NARRATIVE
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On 04/18/2022 at 11:00 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Rosa Carreno for a case management visit and explained the reason for the visit to them. Present was licensee, their spouse, two sons, and daughter.

LPA informed licensee that due to their failure to report an incident that occurred in November 2021, Type A deficiency is being cited today. LPA Cervantes informed licensee, Rosa Carreno, that this report dated 04/18/2022 documents one type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of the children in care. Also, LPA Cervantes informed the licensee, Rosa Carreno, to provide a copy of this licensing report dated 04/18/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

LPA Cervantes provided copy of regulation section 102416.2 to the licensee, Rosa Carreno.

Exit interview conducted and report was reviewed with licensee, Rosa Carreno. 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: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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Document Has Been Signed on 04/18/2022 12:08 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Susy Cervantes On 04/18/2022 at 09:40 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CARRENO, ROSA
FACILITY NUMBER: 434406583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/19/2022
Section Cited
CCR
102416.2(a)

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102416.2(a) Reporting Requirements
The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). This requirement was not met as evidenced by:
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Licensee shall review section 102416.2 and submit statement to the department that she understands the reporting requirements including mandated deadlines
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Based on record review, licensee failed to report their spouse's arrest in a timely manner which poses an immediate risk to the health, safety, and personal rights of the 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:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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