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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274409364
Report Date: 11/04/2022
Date Signed: 11/05/2022 03:21:18 PM


Document Has Been Signed on 11/05/2022 03:21 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:PEREZ, GLORIAFACILITY NUMBER:
274409364
ADMINISTRATOR:GLORIA PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 754-2362
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY:14CENSUS: 0DATE:
11/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Diana Edeza TorresTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced Case Management inspection to the home today. LPA met with Diana Edeza Torres, licensee's helper. LPA was informed that licensee was not home today and childcare was not provided today. LPA explained over the phone to licensee this inspection is a follow up on the previous investigation conducted by the IB investigator Mariana Lomeli on an incident where a bookcase fell over and injured a child in care. Licensee instructed LPA to conduct the inspection with helper Diana. During the investigation was concluded the bookcase was missing one of the four wheels, making the bookcase unstable and unsafe. Licensee is being issued a type A deficiency today as a result of the investigation.

Licensee Gloria Perez was notified today, over the phone she needs to attend an in-office meeting with one of the Licensing Program Managers on November 15, 2022 at 10:00 AM.
Appeal Rights were left with Diana to be provided to Gloria Perez, forms are both in Spanish and in English.

LPA discussed the requirements of AB633 to licensee over the phone and in person to licensee's helper Diana and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.
*********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: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 2


Document Has Been Signed on 11/05/2022 03:21 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: PEREZ, GLORIA
FACILITY NUMBER: 274409364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2022
Section Cited

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(a) Each child receiving services from a family childcare home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment
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This regulation was not met as evidenced by: Per IB investigator it was determined that a bookcase had only three wheels, it was determined that the bookcase was unsafe, resulted in the child being injured. This violation poses an immediate risk to the health, safety or Personal rights to children in care.
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LPA discussed the requirements of AB633 to licensee's helper and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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