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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403705
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:24:37 PM


Document Has Been Signed on 08/28/2023 03:24 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:GOMEZ, LOURDESFACILITY NUMBER:
434403705
ADMINISTRATOR:GOMEZ, LOURDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 445-8590
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 8DATE:
08/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Lourdes GomezTIME COMPLETED:
03:49 PM
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Licensing Program Analyst (LPA) Teodoro Trujillo met licensee Lourdes Gomez and discussed an incident that occurred on 08/17/23.

There were 8 day care children present during this inspection with one
assistant, Esperanza: 2 infants and 6 preschool age.

Licensee has a written plan that will prevent future incidents from happening in her day care home. Licensee will update her parent contract and will submit a copy to the San Jose Regional Office.


Exit interview was conducted. A Notice of Site Visit with a copy of today’s report shall be posted for 30 consecutive days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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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