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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409251
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:34:13 PM


Document Has Been Signed on 06/28/2023 01:34 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:GARZA, CELIAFACILITY NUMBER:
434409251
ADMINISTRATOR:CELIA GARZAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 425-1638
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:14CENSUS: 12DATE:
06/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Celia GarzaTIME COMPLETED:
01:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Celia Garza for a Plan of Correction Visit from 05/10/2023 annual site visit. Present were licensee, licensee's assistant with 12 day care children: one(1) infant, eight(8) preschool age, and three(3) school age.

LPA provided licensee the Letter of Deficiency Citations Cleared for citations from 05/09/23 visit.

Type B deficiencies were cited during today's visit, from previous site visit. See LIC 809D.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Exit interview conducted and report was reviewed in Spanish with the licensee, Celia Garza. 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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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Document Has Been Signed on 06/28/2023 01:34 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: GARZA, CELIA
FACILITY NUMBER: 434409251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2023
Section Cited
CCR
102419(d)(1)

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Admission Procedures and Authorized Representatives Rights: (d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A.... (1) 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
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Licensee will obtain LIC995A for c1, c2, c3 by close of business and will send a copy to the San Jose Regional Office on 06/28/23.
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Based on observation, interview record review, the licensee did not comply with the section cited above in Child 1 (C1), C2, C3 LIC 995A missing which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
06/28/2023
Section Cited
CCR102416.3(a)(4)

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Alterations to Existing Building or Grounds:
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (4) Construction of exterior decks or porches.
This requirement is not met as evidenced by:
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Licensee will submit proof of building permit for storage shed, and patiol constructmion to the San Jose Regional Office by close of business 06/28/2023.
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Side fence was removed, storage room built next to covered Patio, no building permit provided which poses/posed a potential health, safety or personal rights risk to persons 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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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