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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004705
Report Date: 07/15/2021
Date Signed: 07/15/2021 01:58:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PELAEZ, SILVIAFACILITY NUMBER:
414004705
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
07/15/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Silvia PelaezTIME COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Tapia-Mandujano arrived at facility and met with licensee Silvia Pelaez, to do a Plan of Correction for deficiencies cited on 7/12/21 (Refer to LIC 9099D pages for more details). Purpose of the visit was explained. Present in the home are licensee, licensee's husband, licensee's adult son, and 4 infants.

LPA received an updated Child Care Roster and observed Notice of Site Visit posted.

LPA explained and provided a copy of Tittle 22 regulations for capacity of a Small Family Child Care. Capacity worksheet was emailed to licensee.

LPA has cleared deficiencies for over capacity on 7/12/21.

>A copy of this report was emailed to licensee. A signed copy of this report will be kept on file and made available for public review.

Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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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