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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404256
Report Date: 06/05/2020
Date Signed: 06/05/2020 06:21:03 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:VARGAS, ANAFACILITY NUMBER:
434404256
ADMINISTRATOR:VARGAS, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 977-1742
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:14CENSUS: 1DATE:
06/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Ana VargasTIME COMPLETED:
06:00 PM
NARRATIVE
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Due to the COVID-19 padnemic, LPA Janet Tse conducted a case management tele-inspection regarding a child's injury which required medical treatment but not reported to Licensing. LPA observed one child in the home with Licensee today. Present was also Licensee's daughter Yaritza Vargas, who is Licensee's assistant.

A child was injured in the child care home and required medical treatment. Licensee failed to report the incident to Licensing in time.

Deficiency was cited. Notice of site visit was issued and must be posted for 30 days.

A copy of this Licensing report with LPA's signature alone will be emailed to Licensee. In lieu of Licensee's signature, a read receipt of the email will serve as acknowledgement of receipt of this Licensing report by Licensee.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2020
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: VARGAS, ANA
FACILITY NUMBER: 434404256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2020
Section Cited

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Reporting Requirements. The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (1) Medical treatment means treatment by a medical professional, as defined in
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Section 101152(m).
This requirement was not met as evidenced by:
A child was injured in the child care home and required medical treatment. Licensee failed to report the incident to Licensing in time.
This poses a potential risk to the Health, Safety, or Personal Rights of 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: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2020
LIC809 (FAS) - (06/04)
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