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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409819
Report Date: 05/29/2019
Date Signed: 05/29/2019 09:57:38 AM

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:LOPEZ, MARTHAFACILITY NUMBER:
434409819
ADMINISTRATOR:LOPEZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 608-4911
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: DATE:
05/29/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Martha LopezTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Rangel met with Martha Lopez, Licensee, for an unannounced case management inspection.

LPA toured the facility with Licensee and discussed the non-immediate exclusion for a previous resident of the home. Licensee explained that the previous resident moved out of the home September or October of 2018 and lived at the home for one year prior to leaving.

When LPA arrived at the facility, there was one helper with seven day care children (2 infants and 5 preschool age children). The Licensee had briefly left the home in order to drop off a school aged child at school. LPA reminded the Licensee that when there is no assistant present, facility will revert back to the Small capacity.

Deficiency issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
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 2
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: LOPEZ, MARTHA
FACILITY NUMBER: 434409819
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2019
Section Cited
CCR
102416.5(b)(3)
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STAFFING RATIO AND CAPACITY - For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: More than six and up to eight children, without an additional adult attendant, only if the criteria in Section 1597.44 of the Health and Safety Code are met.
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Licensee stated that she will no longer be able to take the school aged child to school in order to ensure that she is present in her home when additional children arrive. Licensee submitted plan of correction to LPA during today's inspection.
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This requirement was not met as evidenced by: LPA observed one adult helper supervising 2 infants and 5 preschool age children. The facility was operating out of ratio. This poses a potential risk to the health and safety 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019
LIC809 (FAS) - (06/04)
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