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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408237
Report Date: 08/24/2022
Date Signed: 08/24/2022 04:05:04 PM

Document Has Been Signed on 08/24/2022 04:05 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:VARGAS, ARGELIAFACILITY NUMBER:
434408237
ADMINISTRATOR:ARGELIA VARGASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 655-6312
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
08/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Agelia VargasTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teodoro Trujillo and Fermin Campos-Jaramillo met licensee Argelia Vargas for a Plan Of Correction (POC) inspection. Licensee was providing care to 4 children, 1 infant and 3 preschool age children.
At arrival LPAs observed that licensee did not have the Facility Evaluation Report (LIC 809), dated 8/18/2022, posted. Licensee was instructed to post the report in accordance with AB633 requirements on 08/18/2022 as a result of a Type A deficiency issued to the Licensee on 08/18/2022. Licensee posted the report today as instructed and she was advised that the report must remain posted through 09/18/2022 (30 days from the initial date of the initial Type A deficiency). Civil penalty of $100.00 was assessed today for failure to have the report posted.

LPAs reviewed the children records for 7 children and observed that although LIC 9224 were signed by parents, Licensee did not provide a copy of LIC 809 Facility Evaluation report dated 08/18/2022 to the parents or children's representative. Licensee was instructed to provide a copy of Facility Evaluation Report dated 08/18/2022 to them and obtain a signed LIC9224.
LPAs observed in the Guardian system and report dated 8/24/22 that Licensee’s son, Uriel Vargas, has submitted a live scan application to obtain a criminal record clearance or an exemption. Licensee stated her son has moved out of the Family Child Care Home (FCCH) and provided LPAs with her son’s current address and contact information.
LPAs observed on 08/18/2022 and during today’s inspection that Licensee has converted the garage of the home into living quarters. There is one adult (Daisy Vargas) and minor children ages 12, 11, 5 living in the converted garage, Daisy has not obtained criminal record clearances or exemptions.
*********************This report dated today continues on Page 2.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VARGAS, ARGELIA
FACILITY NUMBER: 434408237
VISIT DATE: 08/24/2022
NARRATIVE
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 Licensee shall remove access from living quarters unitl she obtains a criminal record clearance or an exemption. Licensee understands that every adult residing, working, or volunteering in a FCCH need to have a criminal records clearance or an exemption. A Type A deficiency was cited today for Daisy not having criminal record clearance or exemption. A Civil Penalty of $500 was assessed today. Licensee understand this is a Type A deficiency.

LPAs advised Licensee that an updated fire inspection request will be sent to the San Jose Fire Department to address the converted garage. Licensee agreed to submit an updated sketch of the premises which will include the converted garage.
Licensee agreed to obtain proof of not active tuberculosis for the following adults: Daisy Vargas and Uriel Vargas.

Licensee agreed to obtain a signed Criminal Records Statement form LIC508 for the following adults. Daisy Vargas and Uriel Vargas.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies 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.

LPAs Teodoro Trujillo and Fermin Campos-Jarmillo informed licensee Argelia Vargas that this report dated 08/24/2022 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.



Also, LPAs Teodoro Trujillo and Fermin Campos-Jarmillo informed the licensee Argelia Vargas to provide a copy of this licensing report dated 08/24/2022 that documents any Type A citation(s) 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
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2022 04:05 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/24/2022 at 12:30 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: VARGAS, ARGELIA
FACILITY NUMBER: 434408237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
CCR
102370(d)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
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Licensee shall immediately deny access to the converted garage and obtain a criminal record clearance or exemption for Daisy Vargas, meanwhile she cannot be present in the premises or work until a criminal background found residing in the licensee’s premises: Daisy Vargas.
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(1) Obtain a California clearance or a criminal record exemption as required by the Department.This requirement was not met as evidenced by Licensee tennant, Daisy Vargas has not obtained criminal record clearance or exemption as of 08/24/2022, this poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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This individual may not reside, work or be present until she obtains a criminal records clearance or exemption.LPA discussed the requirements of AB 633 with licensee Argelia Vargas and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) LPAs explained the use and purpose of the form LIC9224

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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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2022 04:05 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/24/2022 at 01:02 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: VARGAS, ARGELIA
FACILITY NUMBER: 434408237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
102416.3(a)(6)

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Alterations to Existing Buildings or Grounds:
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:


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Licensee will provide a new faclity skcetch to Licensing by the end of business day 09/07/2022.
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(6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.
This requirement was not met as evidenced by, Licensee has converted the home's garage to living quarter, and did not inform Licensing Department, this poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
09/07/2022
Section Cited
CCR102369(b)(9)

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(9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
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Licensee will submit proof of not having active tuberculosis for Daisy Vargas and Uriel Vargas to Licensing Office by the end of business 09/07/2022.
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This requirement was not met as evidenced by two adults, Daisy Vargas and Uriel Vargas do not have proof of negative Tuberculosis test,. 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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/24/2022 04:05 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/24/2022 at 02:10 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: VARGAS, ARGELIA
FACILITY NUMBER: 434408237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
102370(c)

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Criminal Record Clearance
(c) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
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Licensse will submitt to Licensing Office a signed Criminal Record Statement LIC 508 from Daisy Vargas and Uriel Vargas by close of business 09/07/2022
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This requirement was not met as evidenced by, Licensee does not have on file LIC 508 forms for Daisy Vargas and Uriel Vargas. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
09/07/2022
Section Cited
HSC1596.8595

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(a)(1) Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation ..., will create a direct and immediate risk to the health, safety, or personal rights...posted for 30 consecutive days.
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Licensee will post LIC 809 dated 08/18/2022 immediately by 08/24/2022.
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This requirement was not met as evidenced by Licensee not posting LIC 809 dated 08/18/2022. 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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


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Document Has Been Signed on 08/24/2022 04:05 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 08/24/2022 at 02:34 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: VARGAS, ARGELIA
FACILITY NUMBER: 434408237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
HSC
1596.8595(c)(1)

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Health and Safety Code Section 1596.8595 (c) A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
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Licensee will provide a copy of LIC 809 dated 08/18/2022 and will obtain parents signatures by the next business day or next day children are in care on LIC 9224 and keep in childrens files.
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This requirement was not met as evidenced by Licensee stated she provided LIC 9224 for parents to sign but did not provide LIC 809 dated 08/18/2022. 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:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VARGAS, ARGELIA
FACILITY NUMBER: 434408237
VISIT DATE: 08/24/2022
NARRATIVE
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Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

On the inspection date of 08/18/2022, Licensee was cited for not having Mandated Reporter Training for herself and her assistant Celeste. Plan of Correction (POC) was missing within that Report. Licensee will correct POC by submitting to Licensing Office a completed Mandated Reporter Training certificates for herself and assistant Celeste.

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: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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