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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434401958
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:26:27 PM


Document Has Been Signed on 04/12/2023 03:26 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:ARGUELLES, BERTHAFACILITY NUMBER:
434401958
ADMINISTRATOR:ARGUELLES, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 243-8267
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:14CENSUS: 5DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Bertha ArguellesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo met with Bertha Arguelles, licensee. LPA informed licensee that the purpose of the inspection was to return the children files that were taken for photocopying in the Licensing Program office in San Jose. LPA returned to licensee the files for ch1, ch2, and ch3 (LIC811). LPA observed that licensee's helper Gloria Garcia was present in the home. LPA observed five children were in care included two infants and three preschool age. Licensee Bertha Arguelles provided LPA with copies of the following documents of her former helper Elda Diaz Cendejas: Job application, livescan form, DOJ letter, CPR/First Aid card, and a copy of licensee's personal notes on payments to Elda Diaz Cendejas.

No deficiencies were cited during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, 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: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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