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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403705
Report Date: 07/10/2019
Date Signed: 07/10/2019 10:04:40 AM

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:GOMEZ, LOURDES & VICTORFACILITY NUMBER:
434403705
ADMINISTRATOR:GOMEZ, LOURDES & VICTORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 445-8590
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 7DATE:
07/10/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Lourdes GomezTIME COMPLETED:
10:10 AM
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LPA Janet Tse met with licensee Lourdes Gomez for a Case Management inspection. LPA explained the nature of today's inspection to Licensee. LPA observed seven children including two infants with Licensee and two assistants. Present were also Licensee's grandchildren ages 10 and 15 1/2 who reside in the home.

LPA obtained a copy of the roster of the children today. LPA observed a separate and barricaded play area with age appropriate and materials for the infants. LPA reviewed seven children's files, and observed the signed LIC 9224 Acknowledgement of Receipt of Licensing Reports for the type A deficiencies cited on 05/10/2019 and 04/24/2019 are in each child's file. Plan of Corrections for the deficiencies cited have been previously received by LPA.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
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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