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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274405904
Report Date: 04/06/2022
Date Signed: 04/06/2022 05:01:12 PM


Document Has Been Signed on 04/06/2022 05:01 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:ROCHA, GRACIELAFACILITY NUMBER:
274405904
ADMINISTRATOR:ROCHA, GRACIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 633-2106
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY:14CENSUS: 2DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Graciela RochaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with licensee Graciela Rocha in a case management inspection. LPA observed that two children were in care today, included one infant and one preschool age. Licensee's husband, Andres was also in the home. LPA obtained a copy of the children's roster.

Licensee failed to report to Licensing Department an unusual incident that happened in her home in the past month of February 2022.

A deficiency type B was cited today. Appeal rights was printed and provided to licensee.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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Document Has Been Signed on 04/06/2022 05:01 PM - It Cannot Be Edited

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: ROCHA, GRACIELA
FACILITY NUMBER: 274405904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited

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 Reporting requirements
102416.2 (f)(2) Reportable acts of violence include, but are not limited to, those that occur whenever any child in care is a victim of, or subjected to witnessing, others' use of great physical force resulting in bodily harm, or dangerous activity, such as illegal drug use or gunfire.
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This regulation was not met as evidenced by: Licensee did not inform Licensing Department that her home was raided by the law enforcement in the past month of February 2022. This is a violation to the Child Care Regulations and represent a potential risk to the 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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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