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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404552
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:33:49 PM


Document Has Been Signed on 04/01/2022 02:33 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:ALVAREZ, GLORIAFACILITY NUMBER:
434404552
ADMINISTRATOR:ALVAREZ, GLORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 729-4718
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 2DATE:
04/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Gloria AlvarezTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Gloria Alvarez for a Plan of Correction visit. Present were licensee, licensee's adult son, adult daughter and her husband with their two week old infant and 12 year old son, adult granddaughter and two day care children. Licensee's daughter and her family stopped by to pick up 12 year old son during visit. They did not have contact with day care children.

LPA observed licensee cleaned kitchen and counters. All chemicals, medicines, and items observed during visit on 03/11/2022 have been removed and not accessible to children. LPA observed a new child in care and requested to see child's file. Child 1 is missing LIC995, LIC627 and LIC9224 for report dated on 03/11/2022. LPA observed child was not listed on the children's roster.

The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/01/2022 02:33 PM - It Cannot Be Edited

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: ALVAREZ, GLORIA
FACILITY NUMBER: 434404552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited

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An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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This requirement was not met as evidenced by child 1 is missing LIC627. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
04/08/2022
Section Cited

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidenced by child 1 was not listed on the roster.
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This poses a potential risk Health, Safety Personal Rights risk to 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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/01/2022 02:33 PM - It Cannot Be Edited

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: ALVAREZ, GLORIA
FACILITY NUMBER: 434404552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited

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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
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This requirement was not met as evidenced by child 1 is missing LIC995. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
04/08/2022
Section Cited

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A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
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This requirement was not met as evidenced by LPAs observed child 1 is missing LIC9224 for Type A citation issued on 03/11/2022. This poses a potential risk Health, Safety Personal Rights risk to 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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3