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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415899
Report Date: 04/14/2022
Date Signed: 04/14/2022 02:58:06 PM

Document Has Been Signed on 04/14/2022 02:58 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: 15CENSUS: 11DATE:
04/14/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hermita Ana Lazo SamaniegoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Hermita Ana Lazo Samaniego for a Plan of Correction visit. Present were licensee, licensee's assistants Shirley Rodriguez and Guiselle Ruiz, licensee's daughter (12 years old) and nine day care children including two infants. Licensee's nephew Luis Valle Murrillos, licensee's husband and two additional children arrived a short time later.

LPA observed facility was in ratio. LPA observed LIC508, MMR and TB test for assistant Guiselle Ruiz. Guiselle is scheduled to take Mandated Reporter training on 04/15/2022 and update her pertussis vaccine on 04/23/2022. All children had a signed LIC9224 for report dated on 04/05/2022.

No deficiency was cited

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: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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