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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412791
Report Date: 03/18/2024
Date Signed: 03/19/2024 02:23:46 PM

Document Has Been Signed on 03/19/2024 02:23 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TORRES, RITAFACILITY NUMBER:
434412791
ADMINISTRATOR:TORRES, RITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 216-0586
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rita TorresTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts(LPA's) Anna Morales and Deanna Villagrana conducted a Case Management inspection and was met by Licensee Rita Torres. Present were two assistants, three infants and six preschool aged children.

During the course of this inspection, LPA's were unable to observe past Infant Safe Sleep logs for Nine (9) infants.

A TYPE B deficiency is being issued at today's inspection and follows on LIC809(D). Appeal Rights were given.

Exit interview was conducted with Licensee Rita Torres
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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 03/19/2024 02:23 PM - It Cannot Be Edited


Created By: Anna Morales On 03/18/2024 at 01:56 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: TORRES, RITA
FACILITY NUMBER: 434412791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2024
Section Cited
CCR
102421(a)(1)

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Child's Records(a)(1) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

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Licensee stated that she will submit a plan to ensure that she keep children's records for three years after the children leave or are terminated and will submit by the POC date
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1) The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child. This requirement is not met as evidence by: LPA's were unable to review nine(9)infant sleeps logs which which poses/posed a potential health, safety or personal rights risk to persons 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
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