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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274450009
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:51:04 PM

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:REYES, ADRIANA & GONZALEZ, GAUDENCIAFACILITY NUMBER:
274450009
ADMINISTRATOR:REYES & GONZALEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 759-2379
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:14CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Adriana Reyes & Gaudencia GonzalezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/16/2021 at 10:40 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensees, Adriana Reyes & Gaudencia Gonzalez, for a case management- deficiencies. Present were licensees with 6 children in care: 5 preschool and 1 infant age.

During the visit, LPA was notified that the facility had an outbreak and did not notify licensing, licensees only notified parents. LPA reminded licensees that outbreaks need to be reported to licensing within 24 hours and an unusual incident report (LIC 624B) needs to be submitted within 7 days.

Type B deficiency was cited during today's visit. Exit interview conducted and report was reviewed with the licensees, Adriana Reyes & Gaudencia Gonzalez. 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: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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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: REYES, ADRIANA & GONZALEZ, GAUDENCIA
FACILITY NUMBER: 274450009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2021
Section Cited

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102416.2(c)(3) Reporting Requirements- In addition to the events specified... the licensee shall report the following events to the Department: A communicable disease outbreak when determined by the local health authority. This requirement was not met as evidenced by:
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Based on interviews, licensees failed to report an outbreak to licensing. This poses a potential risk to the health and safety of 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: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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