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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409221
Report Date: 10/20/2021
Date Signed: 10/20/2021 02:00:45 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:LARA, GABRIELAFACILITY NUMBER:
434409221
ADMINISTRATOR:GABRIELA LARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 843-8720
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 3DATE:
10/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Gabriela LaraTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Anaylyst (LPA) Deanna Villagrana and Licensing Program Manager (LPM) Mary Segura conducted a Case Management visit. Present were licensee, licensee's adult daughter, 10 year old son, three year old daughter and two day care children including one infant. Licensee's husband arrived later during the visit.

The backyard is off limits, however the emergency exit is located in the backyard. LPA and LPM observed a swimming pool with a 4ft fence. The gate did not have a self-latching device. A few inched of water was observed in the pool after a recent rainfall. LPA and LPM observed a pond on the right side of the home that did not have proper fencing. The fence was 4ft 1in and does not close properly. LPA and LPA observed multiple hazards including but not limited to broken toys, work tools, building materials, table saw, loose wire fencing, garbage and dog feces. Several gates are broken and off there hinges. The gate to the very back of the yard is broken and off its hinges allowing kids access to cactus plants, several work tools and building materials. The emergency exit that leads to the sidewalk on Mantelli Dr. is blocked by several weeds, tree branches, building materials and broken toys which obscures the exit. There is a chain on the bottom of the fence that is keeping it shut. LPA and LPM did not observe LIC9224 signed for children present for report on 10/07/2021.

LPA discussed the requirements of AB633 to licensee Gabriela Lara and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee Gabriela shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the 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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 4
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: LARA, GABRIELA
FACILITY NUMBER: 434409221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited

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All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.
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This requirement was not met as evidenced by LPA and LPM observed a pond on the right side of the home that did not have proper fencing. The fence was 4ft 1in and does not close properly. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Type A
10/21/2021
Section Cited

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Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in use.
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This requirement was not met as evidenced by LPA and LPM observed a swimming pool with a 4ft fence. The fence did not have a self-latching device. Water was observed in the pool after a recent rainfall. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: LARA, GABRIELA
FACILITY NUMBER: 434409221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2021
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 LPA and LPM did not observe LIC9224 signed for children present for report on 10/07/2021. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
11/03/2021
Section Cited

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The home shall be free from defects or conditions which might endanger a child. This requirement was not met as evidenced by The emergency exit that leads to the sidewalk on Mantelli Dr. is blocked by several weeds, tree branches, building materials and broken toys which obscures the exit.
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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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: LARA, GABRIELA
FACILITY NUMBER: 434409221
VISIT DATE: 10/20/2021
NARRATIVE
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Exit interview conducted and report was reviewed with the licensee Gabriela Lara.

The following type A and 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.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4