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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407067
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:44:58 PM


Document Has Been Signed on 03/25/2022 03:44 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:DOMINGUEZ, ANAFACILITY NUMBER:
434407067
ADMINISTRATOR:DOMINGUEZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 776-0050
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:14CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Ana DominguezTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Annual Continuation inspection. LPA met with Licensee Ana Dominguez and explained the reason for the inspection. The purpose of this inspection is LPA was unable to conducted staff interview during Required 1 year inspection on 03/04/2022 due to Licensee being out of town. Present during today's inspection were 5 children, whom 1 was infant age, Licensee, and two Assistants.

Staff interview with Licensee Ana Dominguez was conducted during today's inspection. LPA also reviewed Licensee's file and one child's file. Licensee has a valid CPR/1st Aid, which expires on 01/02/2024. LPA also reviewed sleep log.

As a result of this inspection, no deficiencies were cited. Exit interview was conducted and report was reviewed with Licensee Ana Dominguez.

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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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