<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434416299
Report Date:
03/01/2022
Date Signed:
03/01/2022 03:32:10 PM
Document Has Been Signed on
03/01/2022 03:32 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, HERLINDA
FACILITY NUMBER:
434416299
ADMINISTRATOR:
LAZO SAMANIEGO, H.
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(669) 278-5143
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95112
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
3
DATE:
03/01/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Herlinda Lazo
TIME COMPLETED:
03:50 PM
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
Licensing Program Analyst (LPA) Anna Morales conducted a CASE MANAGEMENT VISIT in regards to an incident that occurred on 2/25/2022. This incident was self -reported by the facility to CDSS San Jose Regional Office on 2/28/22.
LPA interviewed the Licensee and other parties involved. LPA toured the facility and playground.
EXIT INTERVIEW WAS CONDUCTED AND REPORT WAS REVIEWED WITH THE LICENSEE NO DEFICIENCIES WERE CITED AT TODAY'S VISIT.
NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAY
SUPERVISORS NAME
:
Diana Stephenson
LICENSING EVALUATOR NAME
:
Anna Morales
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/01/2022
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