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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405137
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:48:57 PM


Document Has Been Signed on 09/27/2022 03:48 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:GAETA, ELIDAFACILITY NUMBER:
434405137
ADMINISTRATOR:GAETA, ELIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-6174
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 0DATE:
09/27/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elida GaetaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Deanna Villagrana and Licensing Program Manager (LPM) Mary Segura conducted a scheduled informal office meeting at the San Jose Regional Office with Licensee Elida Gaeta, her husband Donaciano Gaeta and Daisy Lara, parent of a day care child to discuss issues and citations issued on 08/19/2022.

On 08/19/2022, LPA arrived and asked who was in the home upon arrival. Licensee Elida Gaeta stated it was her and her assistant Norma Galvan Lopez along with the 10 children including five infants. Facility was out of ratio. LPA was in the kitchen area completing report and heard an infant crying. Assistant Norma was washing dishes in the kitchen. LPA asked Norma if all infants were asleep. Norma stated yes. LPA requested to see off limits bedrooms. Licensee Elida was hesitant and stated she needed to call her husband to ensure he was dressed. Licensee opened all doors and LPA observed an un-fingerprinted adult lady identified as Lissette De La Torre Banuelos and an infant in one room. LPA asked if the infant was Lissette's child. Licensee Elida stated it was Lissette's infant and stated the child's name was Ruben who were visiting from Mexico. LPA requested to see passports for both Lissette and infant. Licensee Elida then stated infant was actually a day care child and the name was different from what was given. Licensee engaged in conduct inimical by lying about who was present in the home and identifying an additional day care child in the home. LPA observed three infants asleep in play yards with blankets. One infant was on a boppy pillow in a play yard. Licensee did not have a Safe Sleep Log for infants in care.

LPM Mary Segura, explained that if there are continued serious deficiencies cited against the facility including but not limited to citations for uncleared adults in the home, staying within Ratio and Infant Safe Sleep, the license may be referred to legal for possible administrative action, which could include revocation of the facility license. The facility will be monitored more frequently to ensure that the facility is maintaining compliance with Title 22 regulations. Licensee was provided a copy of the Safe Sleep Regulations and Ratio Chart.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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


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: GAETA, ELIDA
FACILITY NUMBER: 434405137
VISIT DATE: 09/27/2022
NARRATIVE
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LPM Mary Segura discussed the requirements of AB 633 with Elida Gaeta and provided her with the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the requirements.
Copies of this report must be provided to parents/guardians of children currently in care at this Facility and to parents/guardians of children newly enrolled at this Facility during the next 12 months.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2022 03:48 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: GAETA, ELIDA
FACILITY NUMBER: 434405137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited

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The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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Licensee engaged in conduct inimical by lying about who was present in the home and identifying an additional day care child in the home.
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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: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3