<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415899
Report Date: 02/07/2023
Date Signed: 02/07/2023 10:19:35 AM

Document Has Been Signed on 02/07/2023 10:19 AM - 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: 14CENSUS: 10DATE:
02/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Hermita Lazo SamaniegoTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/07/2023 at 09:15 AM, Licensing Program Analysts (LPAs) Teodoro Trujillo and Susy Cervantes met with licensee, Hermita Ana Lazo Samaniego, for a case management visit to provide an amended LIC 9099D from previous visit 02/03/2023, confirm Type A deficiency reports have been given to parents and the LIC 9224 has been signed, and to provide letter of deficiency clearance for the type A deficiencies received on 02/03/2023. Present were licensee, licensee's assistant Shirley with 10 children in care, four(4) which were infants and six(6) preschool age children.

LPAs observed a copy of the licensing report dated 02/03/2023 with the Type A deficiencies posted next to the front door entrance. Ten(10) Children's files were reviewed, LPAs observed all files had an LIC 9224 signed with parent's signature. Type A deficiency plan of correction letters were received at the San Jose Regional Office by email on 02/06/2023, today LPAs will be providing a letter of deficiency clearance to licensee.

Exit interview conducted and report was reviewed in Spanish with the licensee Hermita Lazo Samaniego. No deficiencies were cited on todays visit.

Notice of site visit was issued and must be 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: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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 1