<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407067
Report Date: 11/26/2019
Date Signed: 11/26/2019 03:16:53 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:DOMINGUEZ, ANAFACILITY NUMBER:
434407067
ADMINISTRATOR:DOMINGUEZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 776-0050
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:14CENSUS: 11DATE:
11/26/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Ana DominguezTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Plan of Correction (POC) inspection. LPA met with Licensee Ana Dominguez and explained the reason for the inspection.

Licensee was cited on 11/05/2019 for Personnel Rights. Licensee stated that she submitted written plan to Licensing office the week of 11/10/2019. Licensee stated that she will forward the written plan by the end of today, 11/26/2019.

No deficiencies have been cited as result of today's inspection. An exit interview was conducted where this report was discussed and provide to Licensee Ana Dominguez. A notice of site visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
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 1