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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415899
Report Date: 03/02/2022
Date Signed: 03/02/2022 01:14:06 PM

Document Has Been Signed on 03/02/2022 01:14 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:LAZO SAMANIEGO, HERMITA ANAFACILITY NUMBER:
434415899
ADMINISTRATOR:HERMITA ANA LAZO SAMANIEGOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 416-6916
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 16CENSUS: 7DATE:
03/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Deanna Villagrana and Teodoro Trujillo met with licensee Hermita Ana Lazo Samaniego for a case management visit. Present were licensee, licensee's assistant Shriley Rodriguez and seven day care children including two infants. Licensee's sister Herlinda Samaniego arrived about 30 minutes later.

LPAs observed licensee's sister did not have a current file at the facility. Licensee's sister is missing Mandated Reporter training certificate, LIC508 and immunization records against pertussis, measles and influenza. LPAs observed children 1, 2 and 3 are missing LIC9224 for Type A citation issued on 12/17/2021. Child 1, 4 and 5 did not have immunization records on file or need to be updated. Child 4's mother sent record to licensee by email during visit. Child 3 is missing LIC9227. Child 1 is missing LIC627. LPA's observed did not observe a current Safe Sleep log for infants in care. It was last updated on 01/18/2022. Licensee stated she has updated the log daily.

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 Deanna Villagrana and Teodoro Trujillo informed licensee Hermita Ana Lazo Samaniego that this report dated 03/02/2022 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 Deanna Villagrana and Teodoro Trujillo informed the licensee Hermita Ana Lazo Samaniego to provide a copy of this licensing report dated 03/02/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/02/2022 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 11:47 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2022
Section Cited
CCR
102418(g)

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Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by Child 1, 4 and 5 did not have immunization records on file or need to be updated.
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Licensee will submit immunization records for children 1, 4, and 5 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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Type B
03/09/2022
Section Cited
CCR102417(g)(7)

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensee will submit LIC627 for child 1 to CCLD by POC date.
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This requirement was not met as evidenced by Child 1 is missing LIC627. 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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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Document Has Been Signed on 03/02/2022 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 11:59 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
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Licensee will submit a Mandated Reporter Certificate for her sister Herlinda Samaniego to CCLD by POC date.
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This requirement was not met as evidenced by Licensee's sister is missing Mandated Reporter training certificate. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
03/09/2022
Section Cited
HSC1597.622(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee will submit immunization record for her sister Herlinda Samaniego to CCLD by POC date.
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This requirement was not met as evidenced by Licensee's sister is missing immunization record agaist pertussis, measles and influenza. 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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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Document Has Been Signed on 03/02/2022 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 12:06 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
CCR
102416.1(a)(11)

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Personnel records shall contain a signed statement regarding their criminal record history, and shall contain specified information. This requirement was not met as evidenced by Licensee's sister is missing
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Licensee will submit LIC508 for her sister Herlinda Samaniego to CCLD by POC date.
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LIC508. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
03/09/2022
Section Cited
CCR102425(c)(2)

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The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. This requirement was not met as
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Licensee will submit LIC9227 for child 3 to CCLD by POC date.
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evidenced by Child 3 is missing LIC9227. 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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2022 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 12:14 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2022
Section Cited
CCR
102425(J)(2)(D)

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Documentation shall be maintained in the infant’s file and be available to the Department for review. This requirement was not met as evidenced by LPA's observed did not observe a current Safe Sleep log for infants in care. It was last updated on 01/18/2022.
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Licensee will submit a statement stating she understands the requirement of keeping a safe sleep log and will submit the log for the week of 03/02/2022-03/11/2022 and submit 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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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Document Has Been Signed on 03/02/2022 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 03/02/2022 at 12:29 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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited
HSC
1596.8595(c)

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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 submit LIC9224 for child 1, 2 and 3 to CCLD by POC date.
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This requirement was not met as evidenced by LPAs observed children 1, 2 and 3 are missing LIC9224 for Type A citation issued on 12/17/2021. 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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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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: LAZO SAMANIEGO, HERMITA ANA
FACILITY NUMBER: 434415899
VISIT DATE: 03/02/2022
NARRATIVE
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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.

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: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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